“Family business?” Navigating the business of treating family

Your 65-year-old mother, who just moved to your town to be closer to you (but really closer to her grandchildren), and who is now on Medicare, wants to be examined by you, her firstborn child and the first doctor in the family. She has primary open-angle glaucoma that was initially diagnosed 2 years ago by another doctor in her previous hometown, and today her IOP is 20 mm Hg OD and OS, with reported adherence to latanoprost every night at bedtime in both eyes. You complete your examination, and she insists on paying you. After briefly considering billing Medicare and just waiving her portion of the fees (she is your mother, after all), you instead have your staff submit the charges to Medicare and duly collect the portion that she’s responsible for. Then you schedule her back to see you again in 3 months for additional testing.

Which of these scenarios is acceptable:
1) waive her portion of the co-pay/deductible; 2) not charge her insurance at all; or 3) bill and collect as described? Are any of these options potentially in violation of the law and/or of provider contracts with insurers? Are these ethical?

Surprisingly to some, the Centers for Medicare & Medicaid Services (CMS), as well as many private payers, now have very strong and specific wording in their provider contracts regarding situations involving family members. Additionally, the American Medical Association (AMA) has published guidance for physicians, to which doctors of optometry may also be held accountable. Here’s a closer look at what applies in these situations.

Treating family members

Although it is not illegal to treat a family member, the AMA’s Code of Medical Ethics, Opinion 1.2.1, Treating Self or Family, states the following:

“Treating…a member of one’s own family poses several challenges for physicians, including concerns about professional objectivity, patient autonomy, and informed consent…. When the patient is an immediate family member, the physician’s personal feelings may unduly influence his or her professional medical judgment. Or the physician may fail to probe sensitive areas when taking the medical history or to perform intimate parts of the physical examination. Physicians may feel obligated to provide care for family members despite feeling uncomfortable doing so. They may also be inclined to treat problems that are beyond their expertise or training.

"Similarly, patients may feel uncomfortable receiving care from a family member. A patient may be reluctant to disclose sensitive information or undergo an intimate examination when the physician is an immediate family member. This discomfort may particularly be the case when the patient is a minor child, who may not feel free to refuse care from a parent.”¹

So generally speaking, physicians are encouraged not to treat members of their own family; however, under certain circumstances, it may be acceptable, such as:

• For short-term, minor problems
• In emergency or isolated settings where no other qualified physician is available (in such situations, physicians should not hesitate to treat themselves or family members until another physician becomes available)

Additionally, when treating themselves or family members, doctors are also expected to:

• Document the treatment or care provided and convey relevant information to the patient’s primary care physician.
• Avoid providing sensitive or intimate care, especially for a minor patient who is uncomfortable being treated by a family member.
• Recognize that family members may be reluctant to state their preference for another physician or decline a recommendation for fear of offending the physician.
• Recognize that if tensions develop in the professional relationship with a family member, perhaps as a result of a negative medical outcome, such difficulties may be carried over into the family member’s personal relationship with the physician.¹

Personally, I will see a family member for an annual comprehensive exam, if they insist, and may even consider treating them for very acute, short-term problems as excepted above (eg, subconjunctival hemorrhage, conjunctivitis, etc). However, in these exceptional circumstances, I make a deliberate and conscious effort to examine, diagnose, document, and treat the family member just as I would any other patient who is not a family member. Appropriate documentation is key to upholding standards of care (after all, how many times have I forgotten what I’d told the patient, only to be saved by a well-documented chart?), as well as ensuring the quality of that care and protecting all involved in the event of audits or even malpractice claims, which do sometimes occur between family members.

If so, when and where?

There’s no right or wrong answer to this question; it’s just a matter of time and economics. Early in my career, in those scenarios in which it was acceptable to examine family members, I would see them after hours (usually on a weekend) to avoid taking an appointment slot away from another patient. That soon changed when I realized how much more of my time it took to make a special drive to the office, open the building, turn on the lights and equipment, and perform all the components of the exam without support staff. I quickly decided that if family members wanted to see me and the circumstances warranted it, they would have to schedule an appointment during regular office hours, but at one of our least in-demand times. The increased efficiency has been well worth the pivot for me, but it is certainly a personal decision for each doctor as to what works best.

Billing for examination of a family member

Ethical considerations aside, Medicare and many private insurers provide very strict and specific guidelines regarding the provision of professional services to an immediate family member of a provider. Per the Medicare Carriers Manual (Section 2332), “Charges Imposed by Immediate Relatives of the Patient or Members of the Patient’s Household” are excluded from reimbursement coverage, and “The intent of this exclusion is to bar Medicare payment for items and services that would ordinarily be furnished gratuitously because of the relationship of the beneficiary to the person imposing the charge. This exclusion applies to items and services rendered by providers to immediate relatives of the owner(s) of the provider. It also applies to services rendered by physicians to their immediate relatives and items furnished by suppliers to immediate relatives of the owner(s) of the supplier.”²

So whether we actually would or not, the federal government presumes we would provide eye care services to our immediate relatives at no cost, and therefore prohibits billing Medicare for them, even if the family member insists on paying their portion of the co-pay and deductible. CMS broadly defines the following relationships as within the definition of immediate relative:

• Husband and wife
• Natural or adoptive parent, child, and sibling
• Stepparent, stepchild, stepbrother, and stepsister
• Father-in-law
• Mother-in-law
• Son-in-law
• Daughter-in-law
• Brother-in-law
• Sister-in-law
• Grandparent and grandchild
• Spouse of grandparent and grandchild²

Furthermore, the routine waiving of co-payments (in the absence of significant and documented financial hardship, with good faith attempts to collect those payments) is considered fraudulent and can result in severe fines and penalties, including banishment from further participation in the Medicare and Medicaid programs for offending providers.

Many private insurers have adopted guidelines similar to those of Medicare regarding the submission of insurance claims for family members. Therefore, it is essential to verify the policy with your payers’ provider relations department before submitting any such claims. The Health Insurance Portability and Accountability Act (HIPAA) mandates several requirements for providers that we are well aware of; however, it is less commonly known that HIPAA also makes it a federal crime to defraud private insurance companies, which can result in criminal prosecution and fines as well.³

Finally, state-specific rules and regulations may also apply in some of these situations, so those should also be reviewed before submitting claims for payment to Medicaid and other insurers on behalf of immediate relatives.

Conclusion

In general, it is safest and easiest to simply not examine family members at all, except in emergency situations, and these concerns provide a convenient excuse for providers to avoid doing so. However, should you choose to examine an immediate relative, it is best to avoid billing for those services altogether. Circling back to our original case, however well-intended the provider was, legally speaking, no charges should have been billed to Medicare on behalf of the mother in that scenario. Ethically speaking, the provider and the mother would be better served if someone else managed her chronic glaucoma. Research these issues carefully, decide on your policy, and stick to it. If there is any ambiguity or question as to what to do or what not to do, consult a health care attorney for conclusive legal advice.

References

1. Opinion 1.2.1: treating self or family. In: AMA Code of Medical Ethics. American Medical Association; 2016. Accessed September 17, 2025. https://code-medical-ethics.ama-assn.org/ethics-opinions/treating-self-or-family

2. Interested in treating family members? check this reimbursement advice. American Academy of Professional Coders. October 18, 2019. Accessed September 17, 2025. https://www.aapc.com/codes/coding-newsletters/my-ophthalmology-coding-alert/billing-interested-in-treating-family-members-check-this-reimbursement-advice-162428-article

3. Miller PJ. Pros and cons of offering professional courtesy. Optometry Times. April 14, 2017. Accessed October 29, 2025. https://www.optometrytimes.com/view/pros-and-cons-offering-professional-courtesy