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Insurance cherry picking to maximize reimbursement a good idea?

September 18, 2014
Question:

Hi Jennifer,
First I want you to know that I read your newsletter avidly and am always recommending it to colleagues.

Here is my issue:
I participate with no insurance plans and have no contract with Medicare.
A colleague is in all plans.
He has proposed that I come to his facilities to render services on his patients with him.
If I bill on fees, he thinks reimbursements will be higher than his in network reimbursements.
Any thoughts on this?  Strikes me as not legal. 

Thanks, 
Dr. M

Answer:

Dr. M, thank you for the feedback, passing the newsletter on and the question!  

To answer, the "offer" you have detailed is absolutely not appropriate on a number of levels.  Before I get there, yes, you can work out of another practice location, and you can rent or license space, personnel and/or supplies/equipment from another practitioner at fair market value (which would be a potential option here, although the upside for the referring physician would not be remotely what he is looking for monetarily).  

The situation proposed potentially brings up cherry picking of insurance plans (fraud), kickback exposure because of the sharing of fees for the referrals, and from a practical standpoint, the minute you step foot inside this practice most insurers may treat you as in-network provider depending on how you are performing the billing (potentially at all of your practice locations). Not to mention the cramp down by carriers on patient out of network services... In the past few years there have been notable suits by insurers against in-network/out-of-network collaborations attempting to manipulate and profit off of fee distribution.  Carriers are putting the hard court press on participating docs to keep it all in house.  In addition to the potential exposure listed above, I would also venture your colleague would be risking participating status termination if the pieces are put together - not to mention the balance billing issue created when his patients start receiving bills for their deductibles and co-insurance costs.  

So, as presented - a great way to increase revenue by having an out of network provider - not exactly how this could potentially play out...

Hope this helps, and glad you checked.  Do not let this discourage you from other potential opportunities; if you have the time and desire to expand your practice, there are many arrangements that would pass muster and be appropriate, but as presented, unless I am missing significant facts/safeguards, this does not appear to be one of them. 

Have a potential opportunity to run by Jennifer?  Send her an email or call 516 747 6700 x. 302. 


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