Advanced Primary Care Management- PCP Medicare

[Anonymous]

Anonymous wrote:APCM is a program designed by and put forth by Medicare to reimburse primary care providers for offering non face to face services to their patients. Medicare says the PCP can bill for these services each month even if in a given month that patient doesn’t use the services.

The doctor is not doing anything sketchy or unethical. These are Medicare’s rules and legitimate billing codes that Medicare created.


What is Advanced Primary Care Management (APCM)?
Advanced Primary Care Management (APCM) is a patient-centered approach that allows us, as your primary
care providers, to receive reimbursement for delivering the coordinated, comprehensive, and personalized care
you expect and deserve.
Medicare Expanded Covered Services under APCM– Effective January 2025
Medicare will now reimburse your primary care provider for:
●

24/7 on-call access to healthcare providers
Prior authorizations for medications
Secure online messaging with your provider
Comprehensive care management
Care coordination between hospitals, specialists, home health, physical and occupational therapy
Performance tracking to measure the quality of care provided to Medicare patients
Why Are These Changes Happening?
●

Before January 1, 2025, Medicare did not provide reimbursement for many of these services.
The cost of delivering these services has increased significantly.
○
Adjusted for inflation, Medicare payments to physicians have declined by 33% since 2001.
○
Lower reimbursement rates have caused many physicians to either reduce or discontinue
treating Medicare patients.
■ Currently only 1 in 4 Family Medicine specialists and only 1 in 7 Internal Medicine
specialists accept Medicare patients.
Recognizing the importance of primary care services, The Centers for Medicare & Medicaid Services
(CMS) revised Medicare coverage to ensure payment for these essential services with APCM.
Frequently Asked Questions
Will these changes result in higher costs for me?
APCM is designed to reduce overall healthcare expenses. Patients with secondary insurance are expected to
have no out-of-pocket expenses. Depending on your insurance, you may have a monthly copay of $3–$10. At
the start of the year, the copay may be subject to your deductible and higher initial cost.
What if I want to stop these services?
You have the right to stop the billing for these services at any time, effective at the end of the calendar month.
What if I do not want to sign up for APCM?
Right now, APCM participation is not mandatory. However, in the future, it may be required for us to continue to
care for medicare patients.
Your provider will review the APCM consent form to sign during your visit.

So, you may want to read my previous comments as it looks like you may have not.

Yes, this is sketchy because:
1. There was no review of this paperwork or program. It was a form sandwiched between all the forms on the clipboard. No mention of extra billing or cost. The list of services are the same as any patient, so there is no indication of this being an "excepted" set of services. For those just subscribing to Medicare- it looks like they are confirming that Medicare is primary biller.
2. We do not require month to month, non face to face services. They call in a prescription or confirm a drugstore request 2x a year for spouse. None for me.
They do not manage any of our chronic conditions. At all. We do yearly wellness visits only, spouse went in 2 x in Feb, saw 2 different PAs. No doctor.
3. We have **premium** secondary insurance, one of the best in the region and country, for which we pay a lot. They refuse to pay this secondary fee after Medicare. Zilch. Medicare only paid a small fraction of this fee. Now the practice is billing us the remainder. We owe $300 total for Jan,Feb, and March. I see there will be another 100 due for April. So $1200 a year for doctors we do not see, services we do not have. What? We might as well join a concierge practice, for more $$ if we are going to have to do it. I think concierge practices compound the problem, but here we are.

How is this not sketchy again? I mean, it's apparently not Medicare fraud, obviously there was a law passed to do it. But, yes, it's unethical and I think fraudulent. I am being billed for services I do not receive.

[Anonymous]

Anonymous wrote:

Anonymous wrote:APCM is a program designed by and put forth by Medicare to reimburse primary care providers for offering non face to face services to their patients. Medicare says the PCP can bill for these services each month even if in a given month that patient doesn’t use the services.

The doctor is not doing anything sketchy or unethical. These are Medicare’s rules and legitimate billing codes that Medicare created.


What is Advanced Primary Care Management (APCM)?
Advanced Primary Care Management (APCM) is a patient-centered approach that allows us, as your primary
care providers, to receive reimbursement for delivering the coordinated, comprehensive, and personalized care
you expect and deserve.
Medicare Expanded Covered Services under APCM– Effective January 2025
Medicare will now reimburse your primary care provider for:
●

24/7 on-call access to healthcare providers
Prior authorizations for medications
Secure online messaging with your provider
Comprehensive care management
Care coordination between hospitals, specialists, home health, physical and occupational therapy
Performance tracking to measure the quality of care provided to Medicare patients
Why Are These Changes Happening?
●

Before January 1, 2025, Medicare did not provide reimbursement for many of these services.
The cost of delivering these services has increased significantly.
○
Adjusted for inflation, Medicare payments to physicians have declined by 33% since 2001.
○
Lower reimbursement rates have caused many physicians to either reduce or discontinue
treating Medicare patients.
■ Currently only 1 in 4 Family Medicine specialists and only 1 in 7 Internal Medicine
specialists accept Medicare patients.
Recognizing the importance of primary care services, The Centers for Medicare & Medicaid Services
(CMS) revised Medicare coverage to ensure payment for these essential services with APCM.
Frequently Asked Questions
Will these changes result in higher costs for me?
APCM is designed to reduce overall healthcare expenses. Patients with secondary insurance are expected to
have no out-of-pocket expenses. Depending on your insurance, you may have a monthly copay of $3–$10. At
the start of the year, the copay may be subject to your deductible and higher initial cost.
What if I want to stop these services?
You have the right to stop the billing for these services at any time, effective at the end of the calendar month.
What if I do not want to sign up for APCM?
Right now, APCM participation is not mandatory. However, in the future, it may be required for us to continue to
care for medicare patients.
Your provider will review the APCM consent form to sign during your visit.

So, you may want to read my previous comments as it looks like you may have not.

Yes, this is sketchy because:
1. There was no review of this paperwork or program. It was a form sandwiched between all the forms on the clipboard. No mention of extra billing or cost. The list of services are the same as any patient, so there is no indication of this being an "excepted" set of services. For those just subscribing to Medicare- it looks like they are confirming that Medicare is primary biller.
2. We do not require month to month, non face to face services. They call in a prescription or confirm a drugstore request 2x a year for spouse. None for me.
They do not manage any of our chronic conditions. At all. We do yearly wellness visits only, spouse went in 2 x in Feb, saw 2 different PAs. No doctor.
3. We have **premium** secondary insurance, one of the best in the region and country, for which we pay a lot. They refuse to pay this secondary fee after Medicare. Zilch. Medicare only paid a small fraction of this fee. Now the practice is billing us the remainder. We owe $300 total for Jan,Feb, and March. I see there will be another 100 due for April. So $1200 a year for doctors we do not see, services we do not have. What? We might as well join a concierge practice, for more $$ if we are going to have to do it. I think concierge practices compound the problem, but here we are.

How is this not sketchy again? I mean, it's apparently not Medicare fraud, obviously there was a law passed to do it. But, yes, it's unethical and I think fraudulent. I am being billed for services I do not receive.

Oh my goodness. You are just being obtuse in response to multiple posters who have gone out of their way to explain something that isn't even that complicated.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:APCM is a program designed by and put forth by Medicare to reimburse primary care providers for offering non face to face services to their patients. Medicare says the PCP can bill for these services each month even if in a given month that patient doesn’t use the services.

The doctor is not doing anything sketchy or unethical. These are Medicare’s rules and legitimate billing codes that Medicare created.


What is Advanced Primary Care Management (APCM)?
Advanced Primary Care Management (APCM) is a patient-centered approach that allows us, as your primary
care providers, to receive reimbursement for delivering the coordinated, comprehensive, and personalized care
you expect and deserve.
Medicare Expanded Covered Services under APCM– Effective January 2025
Medicare will now reimburse your primary care provider for:
●

24/7 on-call access to healthcare providers
Prior authorizations for medications
Secure online messaging with your provider
Comprehensive care management
Care coordination between hospitals, specialists, home health, physical and occupational therapy
Performance tracking to measure the quality of care provided to Medicare patients
Why Are These Changes Happening?
●

Before January 1, 2025, Medicare did not provide reimbursement for many of these services.
The cost of delivering these services has increased significantly.
○
Adjusted for inflation, Medicare payments to physicians have declined by 33% since 2001.
○
Lower reimbursement rates have caused many physicians to either reduce or discontinue
treating Medicare patients.
■ Currently only 1 in 4 Family Medicine specialists and only 1 in 7 Internal Medicine
specialists accept Medicare patients.
Recognizing the importance of primary care services, The Centers for Medicare & Medicaid Services
(CMS) revised Medicare coverage to ensure payment for these essential services with APCM.
Frequently Asked Questions
Will these changes result in higher costs for me?
APCM is designed to reduce overall healthcare expenses. Patients with secondary insurance are expected to
have no out-of-pocket expenses. Depending on your insurance, you may have a monthly copay of $3–$10. At
the start of the year, the copay may be subject to your deductible and higher initial cost.
What if I want to stop these services?
You have the right to stop the billing for these services at any time, effective at the end of the calendar month.
What if I do not want to sign up for APCM?
Right now, APCM participation is not mandatory. However, in the future, it may be required for us to continue to
care for medicare patients.
Your provider will review the APCM consent form to sign during your visit.

So, you may want to read my previous comments as it looks like you may have not.

Yes, this is sketchy because:
1. There was no review of this paperwork or program. It was a form sandwiched between all the forms on the clipboard. No mention of extra billing or cost. The list of services are the same as any patient, so there is no indication of this being an "excepted" set of services. For those just subscribing to Medicare- it looks like they are confirming that Medicare is primary biller.
2. We do not require month to month, non face to face services. They call in a prescription or confirm a drugstore request 2x a year for spouse. None for me.
They do not manage any of our chronic conditions. At all. We do yearly wellness visits only, spouse went in 2 x in Feb, saw 2 different PAs. No doctor.
3. We have **premium** secondary insurance, one of the best in the region and country, for which we pay a lot. They refuse to pay this secondary fee after Medicare. Zilch. Medicare only paid a small fraction of this fee. Now the practice is billing us the remainder. We owe $300 total for Jan,Feb, and March. I see there will be another 100 due for April. So $1200 a year for doctors we do not see, services we do not have. What? We might as well join a concierge practice, for more $$ if we are going to have to do it. I think concierge practices compound the problem, but here we are.

How is this not sketchy again? I mean, it's apparently not Medicare fraud, obviously there was a law passed to do it. But, yes, it's unethical and I think fraudulent. I am being billed for services I do not receive.

Oh my goodness. You are just being obtuse in response to multiple posters who have gone out of their way to explain something that isn't even that complicated.

You are the same poster saying the same thing, with zero comprehension. Just cannot read, apparently.

[Anonymous]

Sounds like these practices are betting on some idea that over 65s are doddering old fools and wouldn't figure this out. This makes me want to forgo taking Medicare later and just stay with my insurance. Better for everyone involved.

[Anonymous]

not the same poster. You are the one not comprehending the concept.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:APCM is a program designed by and put forth by Medicare to reimburse primary care providers for offering non face to face services to their patients. Medicare says the PCP can bill for these services each month even if in a given month that patient doesn’t use the services.

The doctor is not doing anything sketchy or unethical. These are Medicare’s rules and legitimate billing codes that Medicare created.


What is Advanced Primary Care Management (APCM)?
Advanced Primary Care Management (APCM) is a patient-centered approach that allows us, as your primary
care providers, to receive reimbursement for delivering the coordinated, comprehensive, and personalized care
you expect and deserve.
Medicare Expanded Covered Services under APCM– Effective January 2025
Medicare will now reimburse your primary care provider for:
●

24/7 on-call access to healthcare providers
Prior authorizations for medications
Secure online messaging with your provider
Comprehensive care management
Care coordination between hospitals, specialists, home health, physical and occupational therapy
Performance tracking to measure the quality of care provided to Medicare patients
Why Are These Changes Happening?
●

Before January 1, 2025, Medicare did not provide reimbursement for many of these services.
The cost of delivering these services has increased significantly.
○
Adjusted for inflation, Medicare payments to physicians have declined by 33% since 2001.
○
Lower reimbursement rates have caused many physicians to either reduce or discontinue
treating Medicare patients.
■ Currently only 1 in 4 Family Medicine specialists and only 1 in 7 Internal Medicine
specialists accept Medicare patients.
Recognizing the importance of primary care services, The Centers for Medicare & Medicaid Services
(CMS) revised Medicare coverage to ensure payment for these essential services with APCM.
Frequently Asked Questions
Will these changes result in higher costs for me?
APCM is designed to reduce overall healthcare expenses. Patients with secondary insurance are expected to
have no out-of-pocket expenses. Depending on your insurance, you may have a monthly copay of $3–$10. At
the start of the year, the copay may be subject to your deductible and higher initial cost.
What if I want to stop these services?
You have the right to stop the billing for these services at any time, effective at the end of the calendar month.
What if I do not want to sign up for APCM?
Right now, APCM participation is not mandatory. However, in the future, it may be required for us to continue to
care for medicare patients.
Your provider will review the APCM consent form to sign during your visit.

So, you may want to read my previous comments as it looks like you may have not.

Yes, this is sketchy because:
1. There was no review of this paperwork or program. It was a form sandwiched between all the forms on the clipboard. No mention of extra billing or cost. The list of services are the same as any patient, so there is no indication of this being an "excepted" set of services. For those just subscribing to Medicare- it looks like they are confirming that Medicare is primary biller.
2. We do not require month to month, non face to face services. They call in a prescription or confirm a drugstore request 2x a year for spouse. None for me.
They do not manage any of our chronic conditions. At all. We do yearly wellness visits only, spouse went in 2 x in Feb, saw 2 different PAs. No doctor.
3. We have **premium** secondary insurance, one of the best in the region and country, for which we pay a lot. They refuse to pay this secondary fee after Medicare. Zilch. Medicare only paid a small fraction of this fee. Now the practice is billing us the remainder. We owe $300 total for Jan,Feb, and March. I see there will be another 100 due for April. So $1200 a year for doctors we do not see, services we do not have. What? We might as well join a concierge practice, for more $$ if we are going to have to do it. I think concierge practices compound the problem, but here we are.

How is this not sketchy again? I mean, it's apparently not Medicare fraud, obviously there was a law passed to do it. But, yes, it's unethical and I think fraudulent. I am being billed for services I do not receive.

Oh my goodness. You are just being obtuse in response to multiple posters who have gone out of their way to explain something that isn't even that complicated.

You are the same poster saying the same thing, with zero comprehension. Just cannot read, apparently.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Why not just bill higher for an appointment? The fact that Medicare doesn't pay much is not the patient's problem. Why are they billing for nothing that has transpired? How is this not concerning, and yes, sketchy?
I have a specialist who gives out his phone # (hopefully it's not abused, but I'm sure it is,) calls to check in frequently, orders tests from his living room if he has to. Medicare pays a fraction of his bill and yet he isn't finding hidden workarounds to get paid more.And yet my primary care dr, who is managing none of this, is asking for more money for managing this? He's not managing this.

What?

I guess they all can refuse Medicare, but I'm not sure why the patient will fill the gap here considering there's Medicare and Supplemental policy. If the supplemental policy refuses, how is that the patient's problem?

Because the cost of appointments isn't the issue. Mountainous administrative hassle (preauthorizations, script refills, fighting insurance companies, etc) and communication with patients outside of appointments (a million portal messages about side effects, do-I-need-to-be-seen-for-this, etc) is the issue, and this tends to be related to managing people with chronic issues. Could you bill more for appointments to offset that? Maybe in theory; but Medicare isn't going to allow for that. No one is "finding hidden workarounds" here; doctors are just trying to get paid for the labor that has gone unpaid for a very long time and had finally hit completely unsustainable.

That said, it sounds like you pcp doesn't have to manage anything for you. Fine. Just opt out of this fee or whatever.

I don't think it would be unreasonable to charge a small fee for portal messages and RX refills and the like, but to charge a monthly fee when there has been no contact is not ethical IMO.

Ok, given all of your replies in this thread, it's clear you are in a rage about this and can't see reason. Just go to a different doctor if you think this one has an ethics problem.

I'm the one who posted above about ethics and I'm not OP. Just a taxpayer. So there's one other person who thinks it's BS that they can charge without touching her file that month.

+1000

[Anonymous]

DP I understand that practices want to be reimbursed for time spent reviewing charts, etc. for situations like a patient calling in for X reasons, and I understand that this program is not fraudulent, but something about it feels off and like taking advantage (in the negative sense) of what is technically allowed.

[Anonymous]

Anonymous wrote:DP I understand that practices want to be reimbursed for time spent reviewing charts, etc. for situations like a patient calling in for X reasons, and I understand that this program is not fraudulent, but something about it feels off and like taking advantage (in the negative sense) of what is technically allowed.

Yes, agree.

[Anonymous]

OP, why are you going to this provider's office for yearly visits, if there is no need for you to do so?