Practicing Nephrology Without Medicare


After 10 years in solo private practice nephrology, I found my ability to practice hindered by the government programs that regulate healthcare delivery. At the heart of my discontent was my inability to determine the value of my own time. Declining reimbursement, the threat of malpractice litigation, profiling by recovery audit contractors (RAC), increasing practice mandates (a silent taxation of the physician’s time), as well as nonsensical coding and documentation rules, all drained the enthusiasm I had to continue practicing for another 20 years.

Nephrologists interpret laboratory investigations and, together with an understanding of the disease process, intercede before a patient becomes symptomatic. Using a parallel process to analyze my practice and after a review of the available information, I took action. On Oct. 1, 2008, I opted out of Medicare, Medicaid and all private pay insurance agreements. I believe I am the first U.S. nephrologist to implement this practice model. To some, this may seem illogical or unethical. While several facets of my practice are unique, the factors I considered in my decision are common knowledge to all practicing nephrologists.

My purpose in sharing this business paradigm is similar to describing a new disease model. My hope is it will renew our spirit of service to the patient and derail our current assembly line model of healthcare. 

What is it like to practice nephrology without Medicare?

My practice is now “self pay.” I do not require patients to have, nor do I accept, any insurance. There are no co-pays or retainer fees. Patients are expected to pay in full at the end of each visit instead of being billed monthly. My fees are detailed in the Medicare Opt-Out Agreement patients are required to sign (this is Medicare’s rule, not mine). The agreement attests that neither the patient, nor I, will submit charges to Medicare. I charge $180 for a half-hour visit, for example, that covers up to five problems. Patients that require phone management are billed $50 for a 10-minute call and $100 for up to 20 minutes. Dialysis patients pay $150/month, which is all-inclusive for their monthly supervision, lab monitoring and half-hour comprehensive office visit.

Patients with non-government primary insurance are provided with a completed HCFA 1500 form that they can send to their insurer. I advise them they may be reimbursed 50 percent to 80 percent of my charge. This is the patient’s responsibility, however. I am free to charge, and accept as payment, whatever I wish. For select patients, I accept a donation to a food bank box in my office, in lieu of payment.

Patients are seen on time and receive a copy of their clinic note before they leave the office. Patient information isn’t shared with government agencies or insurance companies because pay-for-performance (P4P) mandates no longer pertain to my practice. All labs, tests, investigations, dialysis and prescriptions are covered by the patient’s insurance. Patients are only financially responsible for the time/intensity they spend with me.

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