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

In this Ask MGMA episode, hosts Daniel Williams and Cristy Good tackle a question that often trips up medical practices: Can a provider turn away a patient because of the patient’s insurance or the billing method? They lay out the ethical stakes, compliance rules, and legal pitfalls of selective scheduling. Drawing on CMS guidance and professional standards, Cristy outlines fair-billing best practices and share practical tips for leaders who must balance RVU goals with equal access to care.

Timestamps:
00:00 – Introduction to the Ask MGMA Podcast
01:20 – Ethics and Billing: Can Providers Refuse Patients?
03:22 – Ethical Concerns and Compliance Implications
04:12 – Official Guidelines on Patient Selection
06:27 – Best Practices for Ethical and Compliant Billing
07:53 – Final Thoughts and Resources

Resources:

ASHA Ethical Guidelines
Outsources Strategies

PMC Article

Additional Resources:

• MGMA Playbooks
• MGMA Events
• MGMA Consulting
• MGMA DataDive
• MGMA Stat
• MGMA Podcasts

Email us at [e-mail] if you would like to appear on an episode. If you have a question about your practice that you would like us to answer, send an email to [e-mail]. Don't forget to subscribe to our network wherever you get your podcasts.

Episode Transcript

Daniel Williams (00:06):
Well, hi, everyone, and welcome to the ask
MGMA podcast where we answer thereal world questions that
medical group leaders are askingtoday. I'm one of your hosts,
Daniel Williams, a senior editorat MGMA and joined by cohost
Christy Good, who is MGMA'ssenior adviser. So we have a

(00:27):
interesting question that camein this week. It's about ethics
in billing and more specificallywhether a provider can choose
not to see certain patientsbased on how the visit is
billed. Now it's a nuancedquestion and one that gets to
the heart of fair access,compensation, and compliance.
And all I'm gonna say is thankgoodness Christy Good is here

(00:50):
with us today. So, Christy,welcome. What's going on?

Cristy Good (00:54):
Thank you. Getting ready to be off for a long
holiday weekend. How about you?

Daniel Williams (01:01):
Oh, the same. Yes. I cannot wait. Yeah. We're
recording this the week of July4.
You'd think I'd gotten enoughvacation being in Spain, but I I
haven't. I'm ready for anothervacation. So here we go. So
let's dig right into this. Ithink this is gonna be a short
and sweet episode for everybody,but it's a really important one.
So let's start with questionnumber one. So this is what came

(01:27):
in. A nurse practitionerexpressed interest in seeing OB
patients, but only if thebilling codes for those visits
generate individual work RVUs.Christy, is it ever appropriate
for a provider to pick andchoose patients based on how the
visit is billed?

Cristy Good (01:48):
And when that one came through, I was like, oh my
goodness. She actually the OBGand nurse practitioner actually
preferred not to see patientswho fell under the bundled
diagnosis code for billing, andyou just can't do that. It is
not appropriate or ethical for aprovider to selectively see

(02:11):
patients based on reimbursementor RVU generation. This kind of
practice, sometimes calledbilling gainsmanship, that's
what they call it, underminesequitable care and distorts how
resources are used and violatesboth compliance and professional
standards. Providers areethically obligated to deliver
care based on medical need, notfinancial return.

Daniel Williams (02:32):
So let's dig a little bit deeper in that. What
are specifically some of thoseethical concerns that are tied
to this kind of behavior?

Cristy Good (02:40):
Sure. First, it compromises equitable access to
care. So when providers avoidcertain patients because of
bundled billing codes or payertype, it leads to inequality.
And then second, it underminesintegrity in billing, which
should always be based onaccurate documentation, not how
much reimbursement a codebrings. And then third, it can

(03:01):
violate anti discriminationlaws, especially if it affects
patients on Medicaid or theuninsured.
So, you know, ultimately, itdamages trusts and initially and
in the eyes of the public. Bothwill have problems really
trusting your practice and whatyou do.

Daniel Williams (03:19):
Thanks so much, Christy. So next question then.
How does this tie into officialguidelines from CMS or other
professional organizations?

Cristy Good (03:29):
Well, CMS and commercial payers actively
monitor for unusual billingpatterns, especially those that
appear to game the system.Organizations like AMA stress
that coding should reflectservices rendered, not
reimbursement goals of any type,and any deviation that opens up
the door to compliance riskpenalties and reputational

(03:50):
damage will bring peoplelooking. CMS will come looking
if they even think you're doinganything that is selective
treatment pattern wise.

Daniel Williams (04:01):
Okay. You've convinced me, but I'm just,
curious. Are there any caseswhere it's okay for providers to
limit which patients they see?

Cristy Good (04:12):
Sure. I mean, it's not it's not very many, but, it
must be operationally justifiedand clearly outlined in policy.
So for example, a provider mayfocus on procedures that require
special scheduling like EMGs orcolonoscopies, or they may limit
new patients to preserve panelcapacity as long as it applies

(04:33):
to all patients regardless ofinsurance or visit type.
Assignment models like hospitalshifts also fall under this
category.

Daniel Williams (04:42):
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 dothink a lot of practices
struggle with where the line isbetween operational efficiency
and ethical red flags. So thatis really good at clarification
for our listeners so they know,hey.

(05:03):
These are the things we need tofocus on. We're not being anti
discriminatory or anything else,but these are the procedures and
the services we're reallyfocused on in this particular
practice. So it when we look atthis, it really is about
fairness and transparency. Isthat correct, or am I
overstepping there?

Cristy Good (05:23):
No. Exactly. Any policy that limits patient
access must be uniformly appliedacross payer mix and based on
operational needs, notreimbursement value. When
providers follow that framework,it protects both patients and
the organization.

Daniel Williams (05:38):
Okay. So last few questions. And what are some
of the best practices then thatgroup leaders can use to
navigate these issues?

Cristy Good (05:47):
There's kind of three key steps. The first one
is make sure you develop writtenpolicies that outline provider
panels, patient acceptancecriteria, and RVU allocation.
The second would be to auditregularly to identify and
correct any biases in visit typepatterns or RVU attribution. And
then the third is use blendedcompensation models that balance

(06:10):
productivity with access,quality, and team citizenship.
This discourages cherry pickingbased on our views alone.

Daniel Williams (06:18):
Alright. So if I'm hearing you right, then it
sounds like our views aren't theproblem then. It's how they're
used that matters?

Cristy Good (06:26):
Exactly. RVUs are a useful metric, but they
shouldn't drive clinicaldecision making. We know that. I
mean, I know many that's theirbread and butter for their
reimbursement, but Mhmm. Whenproviders prioritize care
delivery based on billing, itreally distorts their role.
The goal is to balance our viewswith patient access, quality

(06:46):
outcomes, and team basedperformance.

Daniel Williams (06:48):
That makes sense. I mean, you wanna get the
money that you, you know, thatthat is out there for you. But,
again, yeah, you don't want thatto be the that decision maker
and driver of seeing patients ornot. So really good distinction.
Okay.
We've been talking a lot aboutthis, particular issue that came

(07:08):
in this past week. But if peoplewanna know even more about it,
where can our listeners go tolearn more about ethical billing
practices?

Cristy Good (07:18):
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 allabout the correct billing and
coding practices. So those aresome important ones, I would
say. And sometimes, MGMA willhave topics like today on this

(07:39):
topic as well.

Daniel Williams (07:40):
Okay. And, everybody, we will definitely
put those, resources in theepisode show notes. So before we
wrap up then, Christy, any finalthoughts or words of advice for
leaders trying to create fairethical structures around
patient assignment and billing?

Cristy Good (07:58):
I would say the key is to keep your policies
transparent, visit them often,and train your team to
understand what is allowed, butalso what is not allowed and why
it matters. So knowing that why.Ethical billing isn't just about
compliance. It's part ofdelivering high integrity care.
And if you're ever unsure, seeka second opinion with your

(08:20):
compliance team or an outsideadviser.
It's always worth to take thatmoment and say, what am I doing,
and should I be doing this, andis this correct?

Daniel Williams (08:29):
Perfect. Alright. Well, that is gonna do
it for this episode. So,Chrissy, thank you as always for
your insight and clarity onthese, medical practice issues.

Cristy Good (08:38):
Thank you.

Daniel Williams (08:39):
Alright. And thanks to you, our listeners,
for joining us for anotherepisode of ask MGMA. Just as a
reminder, if you've got aquestion you'd like us to
answer, drop it in that MGMAcommunity or reach out through
mgma.com. Let me ask Christy onemore time before we sign off.
What's the best way to get intouch with you?
What's that email address yougive out?

Cristy Good (09:00):
[e-mail] will get you right to us as
well.

Daniel Williams (09:04):
Perfect. Until next time, I'm Daniel Williams,
and we'll talk to you againsoon.