Medicare Supplement Plan & Kaiser

Seems like it may be a multilayered process.

Dr's looking at ways to reduce costs and manage their incomes better. Drop acceptance of insurance and all the overhead that creates. Where's a nice cash source--Medicare if you get a lot of retirees.

So form a concierge medical practice. All providers and facilities opt out of Medicare. Providers then draw salaries from the practice.

In order to generate maximum cash, a retirement living community is involved. As part of the requirements of living in the community, residents are required to use a community based HMO or PPO.

The HMO/PPO then reaches out in two directions. One way it goes to US Govt and becomes appointed/certified --however that works-- as a Medicare Advantage plan and draws its monthly stipend - per head for each of the retirement community's residents. It goes the other way and contracts the concierge medical practice as the provider network to deliver the medical services the HMO is obligated to provide.

The HMO receives the money and doles it out, some for itself, some for the retirement housing administration and some for the medical practice.

The doctors are not violating any MedSupp acceptance rules because they have totally opted out of Medicare. They are just contracted with an HMO to deliver medical services, which they are doing.

Something along those lines is what I would suspect is happening. Segment the activities enough and everything is legal.

You just have no clue about this.

First of all, The Villages is a small city and has nothing in their CC&R's about having to use a single medical group, that would undoubtedly be illegal.

This is ONE medical group in the area, there are many others that accept other plans. There are over 150,000 residents of The Villages, did you even take the time to research the area before making assumptions?

The medical group in question accepts PPO plans from UHC, there is no capitation fee for these plans and my guess is that more people have the PPO than HMO since it allows them to see doctors throughout the state without referral as well as nationally through the UHC Passport plan (my personal book of business, which has no one in The Villages, is 95% PPO and 5% HMO). The RPPO also has $0 deductible for Out of Network situations so has lots of flexibility.

The post just prior to mine deals very specifically with the Medicare participation rules and debunks your 'theory'.

I hope anyone reading this thread understands you are not a licensed agent and have no training, education, or certification qualifications to make any relevant statements regarding Medicare. Those of us who need to spend many hours a year (and significant cost) maintaining our license, certification, and educational requirements have a stake in this, you have nothing.
 
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KP has offices in Atlanta and does operate as a staff model for primary care in their free standing clinics. Some specialty care as well as inpatient is handled by contract with KP.

When they opened offices here 25 yrs ago our pediatrician left private practice to head up their ped department. We were allowed to continue to see him and pay as private patients. That was probably a special exception, not the norm and may not operate that way today.
 
Opt-out providers cannot participate in MA.



As long as the provider has not formally opted-out of Medicare and is not sanctioned by the state licensing board, they can accept MA. Since the provider has not opted-out, they will be listed as a participating or non-participating provider with original Medicare. Participating and non-participating providers have the option of treating or not treating original Medicare beneficiaries in non-emergency situations. The participation agreement does not set a minimum number of OM beneficiaries the provider must treat. Only when the provider decides to treat an original Medicare beneficiary do the rules about filing claims and balance billing kick in.

Medicare Participation Agreement: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms460.pdf

Thanks for letting me down gently.

There is an interesting addition to revenue streams for a retirement village there based on a concentrated government cash source. Apparently takes several college courses in Medicare to specifically understand the mechanics.

I deleted the post.

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Those of us who need to spend many hours a year (and significant cost) maintaining our license, certification, and educational requirements have a stake in this, you have nothing.

Hi there.

The above is not a true statement.
LD
 
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