A Collingswood Doctor Offers a Sliding Scale and Free Care to Some Patients. She Still Can't Enroll Anyone on Medicaid.

Practice Spotlight by DPC Insider — Practice Desk
#medicaid#new-jersey#practice-launch#regulation#dpc-operations
Sources: Dr. Idil Kore Brings Membership-Based Primary Care to Collingswood · 42 CFR 455.410 - Enrollment and screening of providers · Ordering/Referring/Prescribing (ORP) - Providers Page, Magellan of Pennsylvania · Provider Enrollment Applications, New Jersey Medicaid Management Information System · Medicaid, Direct Primary Care Frontier · Opting Out of Medicare, Direct Primary Care Frontier · New Jersey, Direct Primary Care Frontier

Dr. Idil Kore says she will see patients who can’t pay. Cimri Medical, the direct primary care practice she has opened at 900 Haddon Ave. in Collingswood, New Jersey, runs a sliding scale, and The Retrospect reports she is currently providing free care to some patients.

“I really believe people should not be priced out of health,” Kore said.

There are still two groups she can’t sign up. Medicaid and Medicare patients.

“We can take care of anybody, insurance or no insurance, with a sliding scale, Medicaid and Medicare are the two exceptions right now, but we’re hopeful that changes,” she told the paper. She called the limit regulatory rather than a statement about who she wants to treat.

The two halves of that sentence do not work the same way at all.

What the practice costs and how it runs

Cimri charges $150 a month for an individual membership and $275 a month for a couple, plus a one-time $100 enrollment fee per member, per The Retrospect. Kore said the figure reflects region, cost of living and what the membership includes. Visits run 30 to 60 minutes. Patients with acute problems may get a same-day or next-day appointment depending on availability. The practice does not bill insurance for primary care visits.

Membership covers the visit and not the rest of medicine. Labs, imaging, prescriptions and specialist care sit outside it, and the practice has negotiated cash pricing with local and national labs and imaging providers and connects patients to discounted medication programs. Cimri also contracts with employers that want to offer primary care as a benefit, including alongside high-deductible plans.

Kore trained at Princeton, took her medical degree at Yale, and completed internal medicine residency at Brigham and Women’s Hospital. She later held faculty appointments at Penn, Northwestern and Emory, then returned to Northwestern’s Kellogg School for an MBA after the pandemic. Her family came to the United States as refugees from Somalia, and she said that history shaped how she thinks about what care should cost. Right now she is the only physician in the practice.

Medicare and Medicaid are not the same problem

Medicare has a documented exit. A physician files an opt-out affidavit and privately contracts with Medicare beneficiaries for covered services, and under section 106(a) of MACRA an affidavit filed on or after June 16, 2015 renews itself every two years. A physician who wants the opt-out to lapse has to tell the contractors in writing at least 30 days before the next period starts. DPC Frontier points out what opting out preserves: those physicians can still order tests, labs and prescriptions, and Medicare fills the orders.

Medicaid has no matching opt-out, and on the ordering question it runs the opposite way.

The rule is about orders, not fees

42 CFR 455.410(b) reads: “The State Medicaid agency must require all ordering or referring physicians or other professionals providing services under the State plan or under a waiver of the plan to be enrolled as participating providers.”

Treat that as plumbing rather than policy. If the membership physician is not enrolled, the state has no valid ordering provider on the claim. DPC Frontier puts the result in one word. Asked whether an unenrolled physician’s orders will be filled, its Medicaid page answers “No,” and says the state “will require that these orders be placed by a Medicaid enrolled physician.”

One Pennsylvania contractor spells out what that does to a claim. Magellan of Pennsylvania, a behavioral health managed care organization operating under county HealthChoices contracts, says on its ORP page that for claims dated January 1, 2018 and after, any claim without an active and eligible ORP practitioner is “subject for denial, retraction and recoupment.” The page scopes itself to the levels of care set by the state Office of Mental Health and Substance Abuse Services, so it speaks to behavioral health rather than to labs or pharmacy. It is the plainest published description of the mechanism, and it is a contractor’s page rather than a statewide rule.

So a Medicaid patient could hold a card that pays for the blood draw and still be unable to use it, because the doctor who ordered the draw is a stranger to the state’s system. DPC Frontier says some DPC physicians work around it by asking the patient to keep a back-up physician who can place the order. That is a harder thing to fix than a monthly fee, and from the outside it looks like nothing at all.

The same page notes that CMS told the Association of American Physicians and Surgeons in 2014 that it saw no problem with private contracts involving Medicaid patients. It calls Kentucky one of the most egregious examples, where a former governor’s executive order made private contracting with Medicaid patients illegal in any form, and it puts Missouri on the other side as a state that has made clear those contracts are permitted. The obstacle it flags across most of the country is the ordering and referring registration.

New Jersey already publishes the form

That same page says it could not locate an ordering and referring enrollment page for New Jersey or Pennsylvania. New Jersey has one. The provider enrollment application at njmmis.com lists “Non-Billing Provider (FD20B)” among its provider types, a category for professionals who order, refer or prescribe for New Jersey Medicaid members without billing the program.

That does not make Kore wrong, and it does not hand her a workaround. Enrolling as a non-billing provider repairs the order. It says nothing about whether the same physician may charge a Medicaid member a monthly fee for the visit, which is a question of state law and the terms of the provider agreement.

One more fact belongs here for completeness. New Jersey has no direct primary care statute. DPC Frontier’s state page says New Jersey “technically has no DPC laws at present.” That is the absence and nothing more. Practices operate in the state regardless, and Kore’s is one of them.

The Open Question

The federal ordering rule is real, and New Jersey’s non-billing enrollment path is real, and no source consulted for this piece answers the question sitting between them. Can a New Jersey physician who enrolls only to order and refer also collect a membership fee from a Medicaid beneficiary for primary care? The njmmis provider enrollment page and the FD-20B application, the two New Jersey documents consulted here, say nothing about it. The 2014 CMS response was informal and general. Until a physician asks New Jersey directly and gets an answer in writing, anyone weighing this is reading tea leaves, and the cautious reading is the one Kore took.