Should physicians ask patients: Which Medicare?

Should emergency physicians ask patients who are most likely covered by Medicare about their insurance coverage? Should they ask whether they're covered by traditional Medicare or a Medicare risk plan? Should either one make any difference?

Physicians aren't supposed to ask for this information directly. But a growing number of providers are feeling the necessity to ask anyway.

"It's an unfortunate reality of managed care that knowing the difference often enables us to decide between what is practical and affordable and what is expensive and unreimbursable when both are just as good," remarks William Gotthold, MD, an emergency physician at Central Washington (state) Hospital in Wenatchee.

Sometimes the difference means the hospital won't get paid for that extra x-ray, even if you feel it's clinically necessary. So should you ask?

Physicians should ask when it's the hospital's policy. But be careful to ask only after you have fully stabilized the patient, says Martin Karpiel, MPA, CMPC, president of Karpiel Associates, an independent managed care consultant in Long Beach, CA.

"You don't want to leave yourself open to allegations that the patient's insurance coverage somehow influenced your medical decision-making," warns Karpiel. That would skirt dangerously close to a federal EMTALA violation, says Karpiel, who specializes in ambulatory care issues.

He says physicians need to strike a balance between their desire to conform with EMTALA and the need to obtain detailed information regarding the patient's medical history, including benefit coverage. "If the patient is covered it means there is likely to be a primary care physician in his past who can offer clinical background," Karpiel says.

ED patients are notorious for showing up unprepared to render reliable documented information. You have to get it out of them verbally, observes Del Brault, president of Emergency Medical Groups Office, a physician billing concern in Arcadia, CA.

But knowing the difference between Medicare and a senior health plan benefits the hospital more than the emergency medical group, Brault says."The [health] plan's capitation level is usually based on the Medicare fee schedule, so in that sense, both programs are similar for the hospital," Brault adds.

For physicians, it's a different story. Medicare risk plans don't usually contract with emergency medical groups. Senior plans are currently paying between 80-100% of the allowable Medicare fee schedule, which currently runs at about 45% of charges.

"The Medicare fee schedule is considerably lower than what any group should accept from a commercial health plan," Brault says.