There has been a lot of discussion on the Facebook group about having a cash practice and seeing Medicare patients. Listen, you are not supposed to charge a Medicare patient cash for a covered service if you are still an enrolled provider with Medicare. It is that simple. There is no debate over this, the regulations are clear.

Most of us have been credentialed with Medicare, Medicaid, and private insurance companies when we first started practice by our employers. I highly doubt there are many nurse practitioners reading this who have not been. Therefore, listen up, this is important.

The administrative pencil pushers and governmental bureaucrats, in all their wisdom, have decided that it is unethical to be charging Medicare patients cash for covered services EVEN if you are operating a 100% cash practice AND the patient is okay with paying for it. Why do they care? It is beyond me; we are saving them money… But to our indebted government, money is unlimited, so it doesn’t matter, I guess… I love working in a highly regulated field…

What could happen if you do bill a Medicare patient cash for a covered service? Well, if a Medicare investigator found out you were charging Medicare patients cash for covered services while you were enrolled with Medicare, they could technically fine you or pursue criminal proceedings. Is this worth their time? I highly doubt that… Why pursue someone who is SAVING them money vs someone who is committing millions of dollars in Medicare fraud? Regardless, elite nurse practitioners do not take dumb risks.

What do you do then if you want to open a niche side practice that accepts cash that provides Medicare covered services?

Well, you have 2 main options:

1. Elect to remain in Medicare and simply do not see Medicare patients (This is what I do and what I recommend doing. You can still see Medicare patients for non covered services though).
2. Opt out of Medicare so you can see Medicare patients and not worry about it (You will not be able to bill Medicare again though at your part-time job unless you opt back in. This could pose issues with future employment. If you are going 100% solo and don’t care, then opt out and don’t worry about it. If you want to keep a part-time job as the Elite Nurse Practitioner Model advocates for, then you need to stay opted in).

If you want to start a concierge direct primary care practice, then go to some other resources out there that discuss this model and Medicare patients in more detail. That is generally a full-time practice that I do not advocate having because it does not provide redundancy in your life which provides financial security and stability. Plus, it is too much of a headache compared to other practices you could start.

On the other hand, if you are wanting to start a niche side practice that only accepts cash while maintaining your Medicare enrolled status, what do you need to do?

1. Don’t accept Medicare patients into your practice.
2. Accept Medicare patients in your practice ONLY if what you are providing is not a covered service.

Number 1 is the easiest step obviously and what I recommend you do… But, if your target market are older individuals who have Medicare, you need to have some plans in place.

If the service you provide is not covered by Medicare, then you can charge the patient cash. How do you know what is covered and what is not? Check out this link:

https://www.medicare.gov/coverage/concierge-care

So for example, medical cannabis evaluations are not covered by Medicare, therefore, I do not worry about this. Stem cell injections are not covered by Medicare, therefore I do not worry about this.

You need to determine if what you are providing is NEVER covered or CAN BE covered by Medicare. CMS states that if you are charging a Medicare patient cash for a service that Medicare usually covers, then you need to provide the patient an “Advance Beneficiary Notice of Noncoverage” (ABN). This basically is a statement that lists why the service is not covered by Medicare. You MUST provide this to your Medicare patients if what you are providing COULD be covered by Medicare.

For example, I have a 66-year-old man who has a testosterone level of 425 but I feel like he could still benefit from treatment. Medicare will not cover this because the total testosterone level is not <300. Therefore, if I provide him an ABN, then I could technically charge him cash (sounds like a pain in the ass right? I don’t even bother… It is not worth the headache).

If the services you are providing are NEVER covered by Medicare, then you can skip this. CMS states that an ABN is not required for items or services that Medicare NEVER covers. Guess what? Medical cannabis, stem cells, aesthetics, IV infusion therapy, etc. are NEVER covered by Medicare. Yeehaw! Now I don’t have to provide an ABN!

This is what happens when the government has its fingers in everything, it just creates more regulations and speed bumps to those who just want to practice freely. Regardless, these are the rules, and you need to understand them.

So remember, if you want to open a cash practice you only have a few options when dealing with Medicare patients:

1. Don’t see Medicare patients and don’t worry about it (highly recommended).
2. Opt out of Medicare (if you want to maintain employment, this is a no-go).
3. See Medicare patients but ensure the service is not covered (if it COULD be covered, you need to provide an ABN. If it is NEVER covered, then you don’t need to worry about it).

What about Medicaid and private insurance? As long as the LLC you are functioning under for your cash practice is not credentialed with these entities, you do not need to worry about it. Check out this article for more information about Medicaid as it is a “greyish” area, but from my understanding, you shouldn’t worry about it like you need to with Medicare.

As always, seek legal counsel when creating a practice where there are grey or questionable areas.