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Physicians seek right to balance-bill under Medicare

Payment cuts have reignited doctors' desires to have beneficiaries pay the difference, which is not allowed under current regulations.

By Victoria Stagg Elliott, amednews staff. Jan. 6, 2003.

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New Orleans -- The American Medical Association will advocate that physicians be allowed to bill Medicare recipients the difference between reimbursement rates and the actual cost of services.

The Association's House of Delegates passed the balance-billing resolution during the Interim Meeting here in December 2002.

"It is imperative that we get back to a system where the economic arrangement is between the doctor and the patient," said Bohn Allen, MD, a Texas delegate. "This gives us the ability to not charge those who can't pay and to make the transaction a reasonable business transaction just like every other business person in this world does."

Physicians who take assignment from Medicare are not allowed to balance-bill. Those who do not accept assignment can bill 10% over Medicare rates. The resolution calls for the AMA to lobby in favor of giving both types of physicians the ability to balance-bill and removing the 10% limit.

Doctors testified that such a change is vital to maintaining seniors' ability to access medical care, in light of reductions in Medicare payment rates. The reimbursement cuts are causing an increasing number of physicians to reduce the number of Medicare patients they will treat, if they take them at all.

"I continue to take care of Medicare patients, but it's a struggle," said Melvyn Sterling, MD, a California delegate. "It's a struggle of such magnitude that I've had to tell my office staff to check with me before they accept any new Medicare patients. It's a struggle that spans this entire country and hurts our profession."

Worries about image

Critics of the resolution accused doctors of attempting to give themselves a raise.

"If we're going to look at it only from the physician side, we'll have a bad PR image problem," said Arthur Traugott, MD, an Illinois delegate. "This is a Band-Aid solution that does not address the problem that the Medicare system is underfunded."

Supporters, however, said physicians are private business people who should have the right to charge as they see fit for their services. They also said that, if the issue is handled appropriately, patients would be amenable to balance billing.

"I'm the one, as an independent business person in a free country, who should be able to determine what my charge is," said Duane Cady, MD, an AMA trustee. "Under the previous system, when balance billing was allowed, I always talked to patients up front before I did any procedure. For example, I would tell them that my charge is $500. Medicare will pay $400, and we would like to be able to bill you for the difference. I can't remember one patient who refused to pay."

Consumer advocates said the onus for fair payment for medical services should be on the government, rather than Medicare beneficiaries.

"We're hearing from thousands of people a month who cannot afford their health care," said Diane Archer, the founder of the Medicare Rights Center.

"Primarily, they can't afford their prescription drugs. They can, today, afford to go to the doctor. That's a tribute to the fact that there are limits on doctors' charges for Medicare recipients. The issue is for the government to pay doctors at a fair rate."

The AMA has long had policies supporting balance billing where allowable by law or contract.

A spokesman for the Centers for Medicare & Medicaid Services said an act of Congress would be required for physicians to be able to balance-bill Medicare patients. He added that agency officials would not want to see Medicare recipients unduly burdened by such charges.

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