Ask MGMA: Is It Ethical to Limit Patients Based on How Visits Are Billed?

Well, hi, everyone, and welcome to the ask MGMA podcast where we answer the real world questions that medical group leaders are asking today. I'm one of your hosts, Daniel Williams, a senior editor at MGMA and joined by cohost Christy Good, who is MGMA's senior adviser. So we have a interesting question that came in this week. It's about ethics in billing and more specifically whether a provider can choose not to see certain patients based on how the visit is billed. Now it's a nuanced question and one that gets to the heart of fair access, compensation, and compliance.

Thank you. Getting ready to be off for a long holiday weekend. How about you?

Oh, the same. Yes. I cannot wait. Yeah. We're recording this the week of July 4. You'd think I'd gotten enough vacation being in Spain, but I I haven't. I'm ready for another vacation. So here we go. So let's dig right into this. I think this is gonna be a short and sweet episode for everybody, but it's a really important one.

And when that one came through, I was like, oh my goodness. She actually the OBG and nurse practitioner actually preferred not to see patients who fell under the bundled diagnosis code for billing, and you just can't do that. It is not appropriate or ethical for a provider to selectively see patients based on reimbursement or RVU generation. This kind of practice, sometimes called billing gainsmanship, that's what they call it, undermines equitable care and distorts how resources are used and violates both compliance and professional standards. Providers are ethically obligated to deliver care based on medical need, not financial return.

So let's dig a little bit deeper in that. What are specifically some of those ethical concerns that are tied to this kind of behavior?

Sure. First, it compromises equitable access to care. So when providers avoid certain patients because of bundled billing codes or payer type, it leads to inequality. And then second, it undermines integrity in billing, which should always be based on accurate documentation, not how much reimbursement a code brings. And then third, it can violate anti discrimination laws, especially if it affects patients on Medicaid or the uninsured.

Thanks so much, Christy. So next question then. How does this tie into official guidelines from CMS or other professional organizations?

Well, CMS and commercial payers actively monitor for unusual billing patterns, especially those that appear to game the system. Organizations like AMA stress that coding should reflect services rendered, not reimbursement goals of any type, and any deviation that opens up the door to compliance risk penalties and reputational damage will bring people looking. CMS will come looking if they even think you're doing anything that is selective treatment pattern wise.

Okay. You've convinced me, but I'm just, curious. Are there any cases where it's okay for providers to limit which patients they see?

Sure. I mean, it's not it's not very many, but, it must be operationally justified and clearly outlined in policy. So for example, a provider may focus on procedures that require special scheduling like EMGs or colonoscopies, or they may limit new patients to preserve panel capacity as long as it applies to all patients regardless of insurance or visit type. Assignment models like hospital shifts also fall under this category.

Okay. That is a helpful distinction, and, I was I'm not gonna try any of these. I just I'm not in a process, but I was just curious. So I do think a lot of practices struggle with where the line is between operational efficiency and ethical red flags. So that is really good at clarification for our listeners so they know, hey.

No. Exactly. Any policy that limits patient access must be uniformly applied across payer mix and based on operational needs, not reimbursement value. When providers follow that framework, it protects both patients and the organization.

Okay. So last few questions. And what are some of the best practices then that group leaders can use to navigate these issues?

There's kind of three key steps. The first one is make sure you develop written policies that outline provider panels, patient acceptance criteria, and RVU allocation. The second would be to audit regularly to identify and correct any biases in visit type patterns or RVU attribution. And then the third is use blended compensation models that balance productivity with access, quality, and team citizenship. This discourages cherry picking based on our views alone.

Alright. So if I'm hearing you right, then it sounds like our views aren't the problem then. It's how they're used that matters?

Exactly. RVUs are a useful metric, but they shouldn't drive clinical decision making. We know that. I mean, I know many that's their bread and butter for their reimbursement, but Mhmm. When providers prioritize care delivery based on billing, it really distorts their role.

That makes sense. I mean, you wanna get the money that you, you know, that that is out there for you. But, again, yeah, you don't want that to be the that decision maker and driver of seeing patients or not. So really good distinction. Okay. We've been talking a lot about this, particular issue that came in this past week. But if people wanna know even more about it, where can our listeners go to learn more about ethical billing practices?

Well, we know that we're gonna link to some of the resources, but the AMA, there's, places like the Journal of Medical Ethics, AAPC are all about the correct billing and coding practices. So those are some important ones, I would say. And sometimes, MGMA will have topics like today on this topic as well.

Okay. And, everybody, we will definitely put those, resources in the episode show notes. So before we wrap up then, Christy, any final thoughts or words of advice for leaders trying to create fair ethical structures around patient assignment and billing?

I would say the key is to keep your policies transparent, visit them often, and train your team to understand what is allowed, but also what is not allowed and why it matters. So knowing that why. Ethical billing isn't just about compliance. It's part of delivering high integrity care. And if you're ever unsure, seek a second opinion with your compliance team or an outside adviser. It's always worth to take that moment and say, what am I doing, and should I be doing this, and is this correct?

Perfect. Alright. Well, that is gonna do it for this episode. So, Chrissy, thank you as always for your insight and clarity on these, medical practice issues.

Thank you.

Alright. And thanks to you, our listeners, for joining us for another episode of ask MGMA. Just as a reminder, if you've got a question you'd like us to answer, drop it in that MGMA community or reach out through mgma.com. Let me ask Christy one more time before we sign off. What's the best way to get in touch with you? What's that email address you give out?

Adviser@MGMA.com will get you right to us as well.

Perfect. Until next time, I'm Daniel Williams, and we'll talk to you again soon.