Insurance Frequently Asked Questions
- Why Dr. Richardson does not participate with Medicare and Commercial Insurance Plans
- Is Dr. Richardson’s practice a “Concierge” medical practice?
Other Insurance Questions
- Will Dr. Richardson be participating with any insurances?
- My insurance representative states that my insurance will send payment directly to Dr. Richardson if requested. Can I just wait until the insurance has paid Dr. Richardson and be billed for the balance?
- Will Dr. Richardson’s staff assist in submitting paperwork to my insurance so I can obtain reimbursement?
- As Dr. Richardson is not a Medicare Provider, will Medicare pay anything for my visits and testing with Dr. Richardson?
- What about testing? Will Medicare pay for tests ordered by Dr. Richardson?
- I am concerned about the expense of future surgery. Will Medicare cover surgery performed by Dr. Richardson?
- I’ve heard that Medicare will still pay part of Dr. Richardson’s fees even if he “does not participate” with Medicare. Will Dr. Richardson bill Medicare for me?
- What is a “Private Contract?
- Will my secondary insurance pay for Dr. Richardson’s visits and testing?
- My secondary insurance representative told me that in order for them to cover Dr. Richardson’s visits they will need an “affidavit” stating that Dr. Richardson has opted out of Medicare. How do I get this?
- My secondary insurance representative told me that in order for them to cover Dr. Richardson’s visits they will need a “denial” from Medicare. How do I get a denial if neither Dr. Richardson nor I am allowed to bill Medicare?
Why doesn’t Dr. Richardson participate with Medicare and Commercial Insurance Plans?
The Practical/Rational Reason.
The Personal/Emotional Reason
In Dr. Richardson’s own words (prior to opting out of Medicare): “I wake up most mornings between 4:30-5:30am and leave for the office before my daughter, Arden, gets up. I am usually done seeing patients by 5:30pm, but the administrative paperwork often keeps me at the office until about 7pm. Fortunately, I have a wonderful commute so am home around 7:30pm. My daughter, Arden, goes to bed at 8pm so this leaves me with only ½ hour each day to spend with my daughter. Saturdays I’m generally at the office all day trying to catch up on my paperwork so the only full day I get to spend with my family is Sunday (and I’m generaly too tired to do anything too exciting).
The “wake up” call sounded in 2010. Arden was waking up in the middle of the night at the least little sound. At first, my wife and I couldn’t figure out why she was not sleeping soundly. We got rid of all DVDs that might have monsters in them, culled through her books, all the usual parenting stuff looking for reasons. One morning she woke up with my alarm at 4:45am. I held her for awhile and asked her if she wouldn’t like to go back to bed as it was still dark.
“No,” she stated, “because when I wake up you’ll be gone and I won’t see you today.”
Now, I know as parents we all are subjected to innocent statements made by our children that have the effect of ripping out our heart, placing it through a blender on “high” and shoving it back into our chest. It is tempting to simply get over the moment (after shedding a few tears) and convince ourselves that our child simply doesn’t understand the complexity of life and that we must continue down the path we have so far traveled.
I could have done the same……
but I won’t.
After a long and detailed evaluation of every possible change I could make in my practice,I came to the realization that the only way I could truly regain enough time to live a life filled with the joys of being with my daughter as she grows would be to eliminate the core inefficiency and driver of practice costs: Medicare and insurance.
So, there you have it. Simple and undeniably important. When faced with the real cost of staying within the system, losing (forever) the chance that I have to share in my daughter’s childhood, there simply is no other choice I am willing to make.
Is Dr. Richardson’s practice a “Concierge” medical practice?
No. There is no “retainer,” or “membership fee” required to be a patient of Dr. Richardson. He is simply returning his practice to a more traditional “fee for service” practice. Similar to a grocery store, restaurant, auto mechanic, etc.,
When Dr. Richardson provides an exam, testing, or surgery, he will expect payment from you at the time the service is provided. No more Medicare or insurance intrusion between you and Dr. Richardson. And, for those concerned about privacy, no more government or insurance “snooping” in your patient chart.
What happens with Dr. Richardson, stays with Dr. Richardson (unless you desire to bill your insurance for reimbursement).
As Dr. Richardson is not a Medicare Provider, will Medicare pay anything for my visits and testing with Dr. Richardson?
No. When a doctor “opts out” of Medicare, the government refuses to pay the doctor or reimburse the patient for any office-related services.
What about testing? Will Medicare pay for tests ordered by Dr. Richardson?
That depends on the test. Any testing performed in Dr. Richardson’s office (visual fields, retinal or optic nerve imaging, etc.) will not be paid for by Medicare. Testing ordered by Dr. Richardson but performed elsewhere (blood testing, MRI, CT scans, etc.) will still be covered by Medicare.
I am concerned about the expense of future surgery. Will Medicare cover surgery performed by Dr. Richardson?
The good news here is that Medicare will cover what is often the most expensive part of surgery: the surgery center or hospital fee plus the anesthesia fee. Dr. Richardson’s surgeon’s fee, however, will not be covered by Medicare.
I’ve heard that Medicare will still pay part of Dr. Richardson’s fees even if he “does not participate” with Medicare. Will Dr. Richardson bill Medicare for me?
This is a common misperception. Medicare participation comes in three flavors: “Participating Providers,” “Non-Participating Providers,” Providers who have “Opted-Out,” and “Disenrolled” doctors. Following is a brief summary of each type of provider:
- Participating Provider. This is the most common type of Medicare provider and was the status of Dr. Richardson through the end of the 2011 calendar year. Participating Providers agree to accept the Medicare “limiting charges” as payment in full. Additionally, they are subject to all of the administrative rules and burdens of the Medicare program.
- Non-Participating Providers. This is an unusual choice for doctors as they must still abide by all of the rules and administrative hassle of being a Medicare Provider. The only benefit to the doctor is that s/he is allowed to bill a small percentage above the usual limiting charges. The doctor is allowed to bill Medicare, but Medicare sends payment to the patient rather than the doctor. This is not what Dr. Richardson is doing.
- Providers who have “Opted Out” of Medicare. Doctors who opt out are no longer required to abide by any of the Medicare rules, regulations, limiting charges or administrative requirements. In order for a Medicare patient to see a doctor who has opted out, both the doctor and patient must enter into a “Private Contract” (Download a copy of Dr. Richardson’s Private Contract here). The wording of a Private Contract is modeled on government regulations and cannot be modified by the patient. The main point of the contract is to outline the government-mandated requirement that neither doctor nor patient bill Medicare for services covered under the terms of the contract.
- Disenrolled Doctors. Doctors who have disenrolled from Medicare are technically not Medicare Providers as they have either refused to sign a contract with Medicare or have terminated their contract. Without a contract, they are not required to abide by any of the Medicare rules, regulations, limiting charges or administrative requirements. No “private contract” is required for patients to see a doctor who has disenrolled and it may be possible for patients to bill Medicare for reimbursement. However, disenrollment is currently a “grey area” and to date few doctors have been willing to take this route for fear of retaliation from the government.
As Dr. Richardson has voluntarily opted out of the Medicare program, Dr. Richardson is prohibited from billing Medicare for all services performed after December 31, 2011. Additionally, you will also not be allowed to bill Medicare for any services (exams, testing, procedures,etc.) performed by Dr. Richardson.
What is a “Private Contract?
In order for Dr. Richardson to care for anyone with Medicare after December 31, 2011, a “Private Contract” must be signed by both the patient and Dr. Richardson. This is a Medicare requirement (yes, even though Dr. Richardson is opting out of Medicare, the government still demands control with regard to all Medicare patients). This contract essentially states the following:
- Dr. Richardson has opted out of Medicare
- This opting out is voluntary and Dr. Richardson has not been excluded from the Medicare program
- You, as the patient, are fully responsible for payment of Dr. Richardson’s fees
- Medicare will not pay Dr. Richardson for his services
- Medicare will not reimburse you for your payments to Dr. Richardson
- Dr. Richardson’s fees are not subject to Medicare’s “limits” or fee schedule
- You agree not to submit a claim to Medicare for Dr. Richardson’s services
- You agree not to ask Dr. Richardson to submit a claim to Medicare
- You understand that you have the option to see another doctor who is a Medicare provider
- You are voluntarily entering into this agreement with Dr. Richardson
- Your supplemental insurance policy may not pay for Dr. Richardson’s services
Will my secondary insurance pay for Dr. Richardson’s visits and testing?
Medi-Gap insurance will not. However, some secondary insurances will “convert to primary” when a doctor has opted out of Medicare. You will have to check with your individual insurance to find out if this is the case with your insurance.
My secondary insurance representative told me that in order for them to cover Dr. Richardson’s visits they will need an “affidavit” stating that Dr. Richardson has opted out of Medicare. How do I get this?
Dr. Richardson’s staff will have copies of this document available for those who need it.
My secondary insurance representative told me that in order for them to cover Dr. Richardson’s visits they will need a “denial” from Medicare. How do I get a denial if neither Dr. Richardson nor I am allowed to bill Medicare?
Welcome to the world of dealing with the inconsistencies of insurance. How can you get a denial from Medicare if you are not allowed to bill Medicare for services performed by Dr. Richardson? Although Dr. Richardson cannot bill Medicare, his staff can provide a written confirmation from Medicare that he has opted out. Copies of this confirmation can be made available to you. This document and a copy of the signed Private Contract should be sufficient documentation that Medicare would deny any service provided by Dr. Richardson.
Other Insurance Questions
Will Dr. Richardson be participating with any insurances?
In order to decrease his administrative burden, Dr. Richardson is “out-of-network” for all insurances and does not submit claims to insurance. Therefore, Dr. Richardson will request payment for his services at the time of your visit. However, as a courtesy, his staff will assist you in submitting a claim for reimbursement from your insurance for the services and testing he provides. Depending upon your insurance benefits, your insurance will then send payment directly to you.
My insurance representative states that my insurance will send payment directly to Dr. Richardson if requested. Can I just wait until the insurance has paid Dr. Richardson and be billed for the balance?
No. Dr. Richardson’s fees have been set based on the assumption that there will be certain efficiencies (or rather, lack of insurance billing inefficiencies). If payment is not made at the time of service, Dr. Richardson would have to raise his fees in order to cover the added work of collecting from insurance and then billing patients for the balance. In order to avoid any confusion, Dr. Richardson does not submit claims directly to your insurance. Rather, his staff will assist you to submit your own claim ensuring that any payments from your insurance will be sent directly to you. If your insurance sends payment to Dr. Richardson in error then Dr. Richardson will return the payment to your insurance company and request that your insurance company reissue a check directly to you.
Will Dr. Richardson’s staff assist in submitting paperwork to my insurance so I can obtain reimbursement?
Since opting out of Medicare and Commercial Insurances almost four years ago I have worked hard to keep my administrative costs down and keep my fees reasonable. Easily one of the most expensive costs of a medical practice is complying with billing codes and government mandates.
Although I do not accept payment directly from Medicare or commercial insurances, as a courtesy my staff have until recently been submitting paperwork to your insurance in an effort to obtain reimbursement for you. As of October 1, 2015, however, the US government now requires that medical billing be done using an obscenely complex coding system called ICD-10. The prior system (called ICD-9) had approximately 14,600 relatively straightforward codes that could be chosen without complicated software. This new system, however, has almost 70,000 unintuitive and complicated codes. Migraine alone has 64 separate codes! But to find them you have to wade through these ICD-10 codes:
- W56.22 Struck by Orca, initial encounter (Yes, that means there is also a separate code for being struck by Orca a second time!)
- V91.07 Burn due to water-skis on fire
- V97.33 Sucked into jet engine
There are many, many more that are just as ridiculous. You can’t make this stuff up!
This new coding system will have zero benefit for you over the old one. Additionally, use of ICD-10 would require that I hire additional staff and purchase expensive coding software. Indeed, the American Medical Association estimates that the cost for a small practice to implement ICD-10 will range from about $56,000 to more than $226,000. The only way to cover such costs would be to raise my fees which neither you nor I wish to see happen.
Instead of raising fees, I have decided not to implement the expensive, time-consuming, and wasteful ICD-10 coding set. My staff and I will still assist you in your efforts to obtain reimbursement from your insurance. You can personally file a claim with your insurance company for my services as an “out of network” provider. You, an individual patient, are not mandated to use ICD-10 codes. However, if your insurance forms have a space for ICD-10 codes we will be leaving those portions of the insurance forms blank.
I hope you will understand why I have chosen this path and that you will agree that it is a better alternative to raising my fees.
Fees & Billing Questions
What will Dr. Richardson be charging for an exam or testing?
In order to make it both simple and affordable to be seen him, Dr. Richardson has set his fees below the standard rates in the Los Angeles area. His most commonly charged fees are as follows:
If you need surgery by Dr. Richardson the fee will depend on the type of surgery and the complexity of your eye disease. Although Dr. Richardson’s staff can provide estimates by phone of what Dr. Richardson’s fee would be for a given surgery, the final fee will depend on the results of your evaluation and testing by Dr. Richardson
I cannot afford even the reduced fees charged by Dr. Richardson. Would Dr. Richardson be willing to accept payments over time?
The fees for Dr. Richardson’s exams, refractions, and in-office testing are due at the time of service. However, if surgery is required (for those who have a documented financial hardship), alternative payment arrangements can be made. This would best be discussed in person with Dr. Richardson’s billing staff as any such arrangement would need to be customized to the financial condition of each individual.
If you have any questions which are not addressed in the above FAQ, please feel free to drop Ana a note. She’ll be happy to help you.