Medicare physician balance billing limitation under attack-a move to allow more billing to patients and an incentive for doctors to drop Medicare

12 May

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How does this legislation sound? Do you see the familiar buzzwords “quality, affordable care” and of course the old standby “choices and decisions with their physicians that best serve their medical needs.”  And then there is the old corporate word “empower.” I never did figure out what that means because the minute you start acting like you are empowered you are reminded exactly who has the real power.

Sometimes I wonder if conservatives have ever used the health care system. What does “independently contract for items and services mean?”. It means a way around balance billing limitations.

Price Introduces Bill to Empower Medicare Patients

Washington, D.C. – Congressman Tom Price, M.D. (R-GA) issued the following statement after introducing H.R. 1700, the Medicare Patient Empowerment Act – legislation that would ensure the rights of Medicare beneficiaries and physicians to freely contract for items and services outside of the Medicare system. Currently under Medicare, beneficiaries and physicians (and other providers) are barred from contracting with one another. While gaining the right to independently contract for items and services under this legislation, Medicare beneficiaries would still retain their Medicare benefits.

“All Americans, including Medicare beneficiaries, should have access to quality, affordable care and the ability to make choices and decisions with their physicians that best serve their medical needs,” said Congressman Price. “The current Medicare system is broken and unsustainable. Seniors are finding it increasingly difficult to find a physician. That is unacceptable and why – in addition to fundamental reforms of the Medicare system – we need common sense approaches to give our seniors the opportunity to make decisions with their physicians without interference from Washington. In addition to providing flexibility of care, this legislation will also help ensure seniors do not lose access to health care professionals and physicians – many of which are finding it harder to treat Medicare patients as the government continues to cut payments for services and impose burdensome regulations. To have the highest quality and access to care in America, we must embrace these types of patient-centered solutions that will provide much-needed flexibility.”

Here is what this proposed legislation really means. It provides an incentive for doctors to not participate in Medicare and be able to balance bill patients above the current limit. How does that sound to you? Do you feel “empowered?”

Politico Pro: ‘Doc Fix’ Hearing To Revive ‘Balance Billing’

A coalition of state medical societies and surgical specialties are backing a “doc fix” bill sponsored by Republican Rep. Tom Price of Georgia that would allow doctors to charge patients more than Medicare pays for various services. The coalition is going to make its case for the Price bill and the practice known as “balance billing” at a hearing of the Energy and Commerce health subcommittee Thursday, according to testimony Politico obtained in advance of the hearing (Coughlin, 5/5).

Currently doctors can balance bill only if they elect not to participate in Medicare for any of their patients for a minimum of two years. Doctors who do not accept assignment may balance bill, but only up to 115% of 95% of Medicare’s allowable charge. The proposed legislation would change that limit.  Dropping out of Medicare for the purpose of balance billing is not as great as it may sound which is why most doctors don’t do it under current rules.  That is because when you factor in the limits, the possible non-collectable charges and the costs associated with billing it is hardly worth it.  However, if the amount that can be balance billed is raised, there is a far greater incentive for doctors to drop Medicare.  For example, if the Medicare allowable charge is $100, today a doctor not accepting Medicare can charge a maximum of $109.00 (115% of $95.00).  To collect an extra $9.00 is hardly worth the effort.  On the other hand, if that cap is raised or eliminated by so-called individual contracting, there is a far greater incentive for doctors to drop Medicare.

MINNEAPOLIS, March 18 – Plans are afoot at both the federal and state levels to allow physicians to bill more for their services to Medicare patients. The AMA has been working with Rep. Tom Price, M.D., R-GA, on a bill, H.R. 1384 (apparently the old bill number from 2009), that would allow physicians to balance bill for the full value of their services under Medicare. This legislation would remove the current 115 percent limit on the amount non-participating physicians can bill Medicare patients. Significantly, it would also preempt state laws that ban balance bill

Here is a good explanation of the Medicare participation and balance billing rules.

The chances of this legislation passing any time soon are not great, but the fact that it is under consideration and has had a hearing recently at a Congressional committee is of concern.  Such moves are in direct response to the so-called “doc fix” or lack thereof.  This is once again one of those unintended consequences that Congress so often creates.  Cutting physician fees under Medicare or Medicaid simply means that another way will be found to make up the money. 

While I don’t doubt that there is considerable room for more efficiency in many physician practices, there is a bottom line for the cost of running a medical business. Since society has determined that physicians are to be among the highest income earners, continuously cutting physician payments under Medicare or private plans has consequences.  To have any impact on overall health care costs it means that physician incomes must drop dramatically (has anyone told them that?), there will be fewer physicians or perhaps you will receive more health care from non-physician professionals.  

There is always a leak to fix

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One Response to “Medicare physician balance billing limitation under attack-a move to allow more billing to patients and an incentive for doctors to drop Medicare”


    1. Health care reform can’t work without more doctors, CNN Money, 4/11/2011 « – Physician Online Publication Resource - May 13, 2011

      [...] Medicare physician balance billing limitation under attack-a move to allow more billing to patients … ( [...]

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