Physician Perspective: DPC & Insurance

It would be nice to completely be rid of the need to worry about patients with insurance, but the reality is that most patients still pay for their health care with insurance. Here's how you can expect to deal with insurance as a DPC clinician.

Note: this is not legal advice. This is all from my personal experience. Please consider consulting an attorney for legal advice.

Can you bill insurance as a DPC provider?

Some practices try to start out by 'dipping their toes' into both models: billing insurance for patients who won't yet commit and membership for those willing to be early adopters. These are known as hybrid models.

My recommendation: don't.

It's likely in your insurance contract / agreement that billing patients anything outside of that contract (like membership fees, larger amounts for procedures, etc.) would void that contract and result in some kind of penalties.

Also, you'll find that it's hard to offer true membership benefits (same or next-day appointments, free telehealth, etc.) when members are competing with fee-for-service patients.

An alternative: patients submit their own CMS-1500 forms

If you're having trouble getting patients to commit to membership, consider offering a cash pay (fee-for-service) list to non-members.

Perhaps you have a standard 99213 office visit charge of $150, plus other charges above and beyond that. The patient then pays you cash, and you can offer them a pre-filled out CMS-1500 (previously known as the HCFA-1500) form, which they can submit to their own insurance at their own risk.

However, be clear that this is a temporary service you're offering to certain patients until a certain date. After that date, they will have to choose whether or not they join as a member or find another PCP.

NOTE ON MEDICARE: see more information below, but this method should not be utilized for Medicare / Medicare eligible patients.

Referring as an out-of-network provider

The one frustration that likely won't go away soon is the frustration of referring insurance-carrying members to specialists.

Most patients use insurance as their preferred method of paying for health care, so as a service to them most clinics do their best to go through prior authorizations and whatever is necessary for the referral process for those patients.

Yes, it's frustrating. But it will get better.

The more you can communicate with patients upfront about what the referral process might look like if they have insurance, the better. That way they know that it's not an issue of you or your staff, but their insurance that's the holdup.

Quick story...

One patient became extremely frustrated that their referral process wasn't going through, and we were the recipients of their anger.

We invited them to come sit with us during the process of referring them, and their demeanor changed dramatically. They were immediately thankful of all we did on their behalf, plus (as a key employee) it encouraged their employer to consider using a different insurance for their employees that worked better with our DPC membership.

For details on what to recommend to patients, see the article on Patient Perspective: DPC & Insurance.

Workers compensation: to contract with or not?

As with traditional insurance, my recommendation is to stay away from contracting with Workers Compensation insurance (both private and state-run companies).

First — there's a potential conflict if you accept membership payments from employer groups as a third-party payer (I recommend you DO accept payments from employers on employees' behalf).

Second — it's unnecessary paperwork that will hold you and your practice back.

How do I deal with workplace injuries for members?

As a member of your clinic, employees have the choice of where they go for their care, regardless of where their injury occurred.

It's a good practice to document where the injury took place in your chart notes, and those would be able to send out if the employee decides to go elsewhere for follow-up care later.

If the employee will likely incur charges beyond membership (perhaps X-rays, DME, medication, or other items), it is likely best to refer / send them to another office that does accept workers comp. Or, if you think that the employee will end up missing work because of the injury, it's also best to refer / send them to another office that can fill out that paperwork.

State laws likely vary, but it's possible that the employee has up to 1 year to submit a workplace injury claim if there are issues. Here's why that can be helpful: if you happen to treat an employee for a workplace injury who is able to return immediately without issue, but then an issue comes up later where they might need time away from work, they can (and should) go to another provider for treatment. You can send over your notes to prove that the injury occurred at the workplace, and the other provider can take over treatment from there.

Medicare

In order to accept Medicare-eligible patients as members, you must opt out of Medicare! This is not an option.

If you do not opt out of Medicare, you're only able to see Medicare patients by billing Medicare as you normally would.

And I don't recommend that — because Medicare compensates family physicians poorly.

Read Opting Out of Medicare for more details and information.

If you are opted out of Medicare, referring Medicare patients to specialists is much like traditional insurance - it depends on what plan they have. If they have a Medicare supplement that's the equivalent of an HMO plan, you won't be able to refer. Typically Medigap plans are much easier to work with.

Medicaid

See your state laws regarding Medicaid for details on whether you need to opt out, or simply not initiate a contract with Medicaid.

As with other insurances, I recommend staying away from contracting with and billing Medicaid.

Similar to traditional insurance, there may be issues referring patients with certain types of state-sponsored insurance. See Patient Perspective: DPC & Insurance for details on what to recommend for patients.

Summary

It may be hard at first, but staying away from contracting with and billing any type of insurance is going to decrease your workload dramatically.

While you likely won't be able to never deal with insurance again because of referrals, DPC removes a lot of barriers that insurance companies put between patients and their primary care provider.