Working with Insurance
Provider Insurance Participation and Billing
Question 1: Will you participate with insurance?
Medicare. Providers credentialed with Medicare who want to avoid billing Medicare for services provided to Medicare patients must opt out of Medicare or avoid seeing Medicare patients. To opt out, the provider must submit the required affidavit to Medicare[1] and execute a private contract with each Medicare patient to bill the patient for services. Providers who opt out of Medicare may not bill Medicare—regardless of location or EIN—except for emergencies.
Private Insurance. Providers participating in private insurance will have a contract for each insurance company, but the connection between the insurance and the networks can be opaque. A contract may give the insurance company the right to include and exclude providers from their networks and to lease their contracted providers to other companies. Each contract should contain the reimbursement, covered services and termination requirements.
Cash Pay Only. A provider may charge patients cash if the provider does not accept the patient’s insurance, (or has opted out of Medicare and has the patient enter a private contract), or if the provided services are clearly not covered by insurance. If there is uncertainty regarding coverage, providers may protect themselves by having the patient sign an Advanced Beneficiary Notice (ABN) informing the patient that their insurance may not cover the service and that the patient will be responsible for the cash price if insurance declines payment.
Scenario 1: Provider A is credentialed with Medicare, but doesn’t accept other insurance. Medicare is billed for services provided to Medicare patients, but all other patients are cash-pay patients, with payment due at the time of service. Provider A may see Medicare patients at another job and bill Medicare for those services.
Scenario 2: Provider B is credentialed with Medicare, but doesn’t see Medicare at their cash clinic. Provider B doesn’t have private insurance contracts. All patients are treated as cash-pay patients, with payment due at the time of service. Provider B may see Medicare patients at another job and bill Medicare for those services.
Scenario 3: Provider C opts out of Medicare and doesn’t participate with private insurance. All patients are charged cash. Medicare patients are required to enter into a private agreement. Provider C may not see Medicare patients at another job and bill Medicare for those services.
| Provider | Medicare | Private Ins |
| Provider A | Participating | Participating |
| Bill Covered Services | Bill Covered Services | |
| Provider B | Participating | Not Participating |
| No Medicare Patients | Charge patients cash | |
| Provider C | Opted Out of Medicare | Not Participating |
| Private Agreement for Cash | Charge patients cash |
Question 2: What services are being provided?
Covered Services. Providers who participate with Medicare or private insurance must bill insurance for covered services, such as routine and acute office visits. Medicare considers the administrative time necessary to manage patients, such as processing referrals, refilling prescriptions, and coordinating care with other providers, included in covered services. “Comprehensive assessments and plans for optimal health” and “extra time” may be covered services. Private insurance covered services typically mirror Medicare. Participating providers who charge patients cash for covered services may be committing fraud.
Non-Covered Services. Medicare and other insurance companies allow providers to charge patients for items and services not covered by their insurance. For services that might be covered by some insurance companies in certain instances, providers should execute an ABN, which is typically required each time the patient receives the service. Specialty labs, for example, often provide a standard ABN for patients to complete with each requisition.
Cash-Pay Services. Services that are never covered by insurance can be treated as cash-pay services. Most insurance contracts do not prohibit providers from selling supplements or providing medical spa services, because insurance contracts do not cover these.[2] ABNs are not required for these services, but providers should consider having patients sign an acknowledgment that these services require payment at the time of service.
Scenario 1: Practice A participates with Medicare but not private insurance. Medicare must be billed for covered services provided to Medicare patients. Medicare patients must complete an ABN each time they receive potentially non-covered services. All other services, (cash-pay services for Medicare patients and all services to non-Medicare patients), are cash-pay.
Scenario 2: Practice B is a Direct Primary Care (DPC) office. Providers have opted-out of Medicare and do not have other insurance contracts. Medicare patients must enter into a private agreement. All services are cash-pay or addressed through practice agreements, (such as a DPC agreement). The practice does not use ABNs because they do not participate with insurance.
Scenario 3: Practice C is a medical spa providing only cash-pay services. Providers participate with Medicare and private insurance through other entities. Patients sign ABNs or acknowledgments that medical spa services are non-covered services/cash-pay services depending on the circumstance.
| Services | Participating | Opt-Out | Cash-Pay |
| Covered | Bill | Private Agreement (Cash) | Cash |
| Non-Covered | Bill (ABN)/Cash | Cash | Cash |
| Cash | Cash | Cash | Cash |
Question 3: What services are required?
Standard of Care. All providers are required to meet the standard of care during each visit as determined by their licensing and training. When patients elect not to follow their provider’s advice, providers should document the advice, alternatives and potential outcomes of the patient’s decision. Providers who have additional traditional training, (such as in pain management), may be held to additional standards of care based on their training.
Additional Care. Providers may offer additional care beyond the standard of care, such as instructing on diet, lifestyles, supplements, exercise and other options not normally covered by traditional providers. Additional care beyond the standard of care may be offered at the provider’s discretion, (while avoiding discrimination). A functional medicine provider, for example, may offer suggestions on meditation to some patients but not others, so long as the implementation of additional care is consistent, (time permitting or other factors).
CAMs. Providers may provide complementary and alternative medicine services (CAMs) that complement traditional patient care. CAMs are not considered part of traditional medicine and are typically not covered by insurance contracts. Each CAM service needs to be addressed on a case-by-case basis to confirm it’s not considered an adjuct therapy, (which are typically considered part of traditional medicine and more likely to be covered by insurance contracts). Dietary counseling, for instance, is an adjunct therapy that may be covered in office visits and/or group visits.
| Scope of Service | Insurance/Required | Opt-Out or Cash/Required | ||
| Standard of Care | X | Yes | X | Yes |
| Covered Services | Bill | Yes | Cash | No |
| Adjunct Therapy | Bill/ABN | No | Cash | No |
| Additional Care | Do not bill | No | Cash | No |
| CAMs | Cash | No | Cash | No |
[1] Opting out of Medicare renews every two years unless cancelled.
[2] State laws and state medical boards may address certain non-covered services.