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Paying a Visit to the Doctor: Current Financial Protections for Medicare Patients When Receiving Physician Services

Issue Brief
  1. Physician Payment Review Commission, “Chapter 9: Assignment and the Participating Physician Program: Current Status,” Annual Report to Congress, March 1998.

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  2. Physician Payment Review Commission, “Appendix E: Trends in Assignment, Participation and Balance Billing,” Annual Report to Congress, 1989.

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  3. Physician Payment Review Commission, “Chapter 9: Assignment and the Participating Physician Program: Current Status,” Annual Report to Congress, March 1998.

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  4. U.S. House of Representatives Committee on Ways and Means, 2004 Green Book, March 2004, WMCP: 108-6, Table 2-34.  Much of that increase is attributed to the implementation of the Participating Physicians program.  Centers for Medicare & Medicaid Services, Data Compendium 2011, Table VI.6, Medicare Participating Physician Program, December 2011.

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  5. Specifically, providers are prohibited from balance billing Medicare beneficiaries who have full Medicaid coverage (dual eligible) or those who receive Medicaid coverage through the Qualified Medicare Beneficiary (QMB) program.  Also, some services are not eligible for balance billing such as clinical diagnostic laboratory services.

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  6. Medigap plans F and G include coverage for balance billing, referred to as “excess charges.” Regarding other supplemental coverage, balance billing is prohibited for Medicare-covered services in the Medicare Advantage program, except for private fee-for-service plans. Among employer-sponsored retiree health plans, potential liability for balance billing depends on the terms of each plan.

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  7. Burney, I., et al., “Medicare Physician Payment Participation, and Reform,” Health Affairs, 3, no.4 1984; and Physician Payment Review Commission, “Chapter 9: Assignment and the Participating Physician Program: Current Status.” Annual Report to Congress, March 1998.

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  8. Ginsburg, P. and P. Lee, “Physician Payment,” in Eli Ginzberg (ed) Health Services Research: Key to Health Policy. Harvard University Press, 1991.

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  9. See statements from Senator Dole (130 Cong.Rec.S. 8373, 8375 (daily ed. June 27, 1984) reprinted in 1984 U.S. Code Cong. & Admin News, Deficit Reduction Act Legislative History at 2156) and Senator Rostenkowski (130 Cong.Rec.H. 7085, 7086 (daily ed. June 27, 1984) reprinted in Legislative History at 1450. Accord, H.Conf.Rep. No. 98-861, reprinted in Deficit Reduction Act Legislative at 751, 1308).

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  10. Holahan, J. and S. Zuckerman, 1989.  “Medicare Mandatory Assignment: An Unnecessary Risk,” Health Affairs, Spring 1989.

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  11. Physician Payment Review Commission, “Appendix E: Trends in Assignment, Participation and Balance Billing,” Annual Report to Congress, 1989.

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  12. Boccuti, C. et al., “Medicare Patients’ Access to Physicians: A Synthesis of the Evidence,” Kaiser Family Foundation, December 2013.

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  13. Medigap plans do not make payments for services provided by opt-out physicians.  Other supplemental insurance plans have the discretion to determine whether or not they will cover services provided by opt-out physicians.

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  14. Automatic renewal provisions were included in 2015 legislation, The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Pub.L. 114-10, 114th Congress (2015-2016).

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  15. Specifically, providers are prohibited from entering into private contracts with Medicare beneficiaries who have full Medicaid coverage (dual eligible) or those who receive Medicaid coverage through the Qualified Medicare Beneficiary (QMB) program.

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  16. Boccuti, C. et al., “Medicare Patients’ Access to Physicians: A Synthesis of the Evidence,” Kaiser Family Foundation, December 2013.

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  17. Dentists, podiatrists, and optometrists did not become eligible to opt out of Medicare until December 2003. Section 603 from the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 added dentists, podiatrists, and optometrists to the definition/list of physicians who may opt out of Medicare.

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  18. Buczko, W. “Provider Opt-Out Under Medicare Private Contracting.” Health Care Financing Review, vol 26, no 2, Winter 2004-2005.

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  19. Melinda Becker, “More Doctors Steer Clear of Medicare, Some Doctors Opt Out of Program Frustrated With Payment Rates and Mounting Rules,” New York Times, July 29, 2013

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  20. See for example, Rabin, Roni C., “When Doctors Stop Taking Insurance,” New York Times, October 1 2012; When physicians state that they “don’t take insurance,” it often indicates that they will bill the patient for the full charge and the patient must seek reimbursement (if applicable) from their insurer, similar to non-participating providers in Medicare.

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  21. Physicians in concierge practices who have opted out of Medicare may charge whatever fees they have outlined in their private contracts with their Medicare patients; Medicare does not reimburse either the physician or the Medicare patient for items or services provided by opt-out physicians.

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  22. Pasquale, F. “The Three Faces of Retainer Care: Crafting a Tailored Regulatory Response,” Yale Journal of Health Policy, Law, and Ethics Vol.7: Iss. 1, Article 2. 2007.

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  23. Hargrave, E., et al. “Retainer-Based Physicians: Characteristics, Impact, and Policy Considerations” Prepared for the Medicare Payment Advisory Commission, March 2010.

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  24. Leonard, D. “Is Concierge Medicine the future of Health Care?” Bloomberg Business Week, November 29, 2012.

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  25. See H.R. 2300 (Empowering Patients First Act of 2015) and H.R.1650 / S.1849 (Medicare Patient Empowerment Act of 2015).

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  26. See “A Better Way: Our Vision for a Confident America,” House Republican proposal, June 22, 2016.

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  27. See The Chairman’s amendment in the nature of a substitute to H.R. 2810 (Medicare Patient Access and Quality Improvement Act of 2013).

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  28. See letter to the Honorable Tom Price from the American Medical Association: https://searchlf.ama-assn.org/letter/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2Fmedicare-patient-empowerment-act-28april2015.pdf.

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  29. Medicare Payment Advisory Commission (MedPAC), Report to Congress: Medicare Payment Policy. Chapter 4, March 2016.

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  30. See, for example, Letter to Speaker John Boehner from state medical associations and state and medical physician societies, May 19, 2011.

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  31. Ginsburg, P. “The Case Against Balance Billing” EyeNet Magazine, American Academy of Ophthalmology, November/December 2010.

     

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