I went into medicine, particularly family practice to take care of people. Insurance regulations and ever changing Medicare laws are interfering with my ability to do this. Also, the amount of paperwork I need to complete and new rules and regulations I need to learn and follow are now dominating the time and energy which I would prefer to spend with patients. The consequences for not obeying these rules and laws is substantial and could involve enormous fines, or time served in a prison.
Medicare rates have not gone up in over 10 years. Private insurance companies generally follow Medicare’s lead. The cost of doing business has risen at least 25% during this same time period. I must survive as a small business owner if I hope to be available to provide for your health care needs.
How does this work?
I will provide you with personalized medical care, and you pay for services provided. We will post our prices so that you know what to expect to pay. For anything unusual, we can negotiate a price. We request payment at the time of service, and will happily provide you with a receipt to submit to your insurance company. If your insurance allows it, you can send it to them for reimbursement, or to have the amount applied to your deductible.
How is this good for patients?
By taking the insurance companies and the government out of the doctor/patient relationship, the doctor works for you. You can rest assured that the choices we make for you about your care are not influenced by your insurance company or any other organization that could gain from you not getting what you need. We will be able to respond to your needs, not the demands of the insurance companies.
This also will benefit the patient through your physician not being bogged down with paperwork and more readily available to care for you.
For which patients will this work best?
This type of medical practice will benefit many different types of patients. Patients who have no insurance or patients who have moderate to high deductibles will probably spend much less money for medical care in this office. Patients who have PPOs (Preferred Provider Organization) who do not need referrals for care may or may not spend slightly more for care with us, we are confident that the level of service will more than make up for the financial cost. Patients with government insurance (Medicare/Tricare) will pay more. Again, we are sure that the service we offer will be worth it for most people. For patients who have HMOs with strict network restrictions, this may be a more difficult proposition if they require you to be seen by a doctor in the insurance company’s network to get referrals. The same is true for MaineCare patients because they require a doctor to accept MaineCare in order for them to refer patients to specialists.
Can I get reimbursed by the insurance company?
That depends on your insurance company. We will be happy to provide you with a receipt and paperwork to submit it to them. You should check with your individual insurance company to find out.
Can I get reimbursed from Medicare?
The government has very strict rules about this. If a doctor has “opted out” of Medicare, he/she cannot submit bills to them for at least 2 years. Medicare patients must sign an acknowledgement of this, with the understanding that they are forbidden from asking for reimbursement for our office visits. This contract must be renewed every 2 years, unless the doctor agrees to start taking Medicare again. These rules apply only to services performed in our office.
I have Medicare; can you refer me to specialists? What about labs, X-rays, medicines and other supplies?
We can still refer you to specialists who take Medicare. We can also order medical services and supplies from vendors who accept Medicare (for oxygen, visiting nurses, physical therapy, medical equipment, etc.)
We can order X-Rays, CT scans, MRIs, and other procedures, which are done outside our office. These should be covered under your insurance just like it always had been. The facility doing the test will bill your insurance company.
Labs that we draw in our office that we send to an outside lab (cholesterol panels, liver and kidney functions, thyroid tests, blood counts, etc.) will also be covered by your insurance as before.
Services that we provide in the office, such as EKGs, breathing tests, urine tests and finger prick blood tests will not be billed to your insurance and will be part of our bill to you.
Prescriptions will be covered under your current insurance as before.
I have commercial insurance; can you refer me to specialists?
For patients who have PPO insurance, there is not usually a referral required. For people who have HMOs with very strict network requirements, we may not be able to do referrals for you because of their rules. We strongly recommend that you check with your insurance company to find out if this will present a problem or not.
How can you charge a fraction of what you did before and still stay in business?
Because of the way the insurance companies and the government have interfered with the pricing of medical services, the prices have become overly inflated. It created a system where doctors were forced to charge far more than they ever expected to receive. Part of the bill goes to offset the administrative costs of cooperating with insurance companies, and allow for mandatory write off amounts.
By cutting out the middlemen, we cut out a lot of confusion, time, and overhead. If we know that we will actually be paid what we charge (like a plumber, bricklayer, or hairdresser), we can cut our rates dramatically.
Why don’t more doctors practice this way?
ALL of the doctors with whom we have talked before making our decision to change our practice are concerned about the future of medicine. Many, who are frightened of making drastic changes, will try to “ride it out,” hoping that things will get better. Some are selling their practices to large groups and hospitals. Some are becoming concierge doctors, charging patients over a thousand dollars a year as a retainer fee. Some are leaving medicine entirely by retiring early or doing something completely different. Charging people what we feel are reasonable rates and working for them directly fits best with our values. We do not expect to get rich. We would like to survive and thrive. The direct pay model has been working well in other parts of the country. It should work well in Maine also. Many of the other solo physicians in our area will be watching us. They may make the same change that we are now if we are successful.
Why have you stopped using an Electronic Health Record (EHR)?
We have found that using the computer for our medical records actually did more to get in the way of patient care than it did to make it easier. Also, we have concerns about maintaining patient privacy with electronic records. Medicare has forced doctors to go to electronic records or face cuts in pay. Because we are opting out of Medicare, this will no longer affect us.
Why must I pay at the time of the visit instead of you sending us a bill?
We could never tell anyone how much a visit really cost in the past, or how much they would owe us in the end because every insurance company paid a different rate for the same services. Now, you will know exactly how much the bill will be because we post our prices in the office and online.
We ask that people pay at the time of service because this helps to keep our costs down, which we, in turn, pass savings on to you. It is really not any different than the way you pay for your groceries when you check out at the supermarket, for your oil change at the mechanic’s, or to have your hair done by your hairstylist or barber.
PLEASE NOTE that we do not want payment to be a barrier for people coming in to see us for their care. If you are financially struggling, please let us know in advance of the visit and we will do our best to work with you.
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