Whenever Medicare changes its rules, providers express interest in opting out of Medicare.
Indeed, many clinicians are wondering about, and opting out of third party payment systems for a variety of reasons (low payment, no payment, and hassle factors), which we will explore in another article.
However, with the Medicare Access and CHIP Reauthorization Act (MACRA) and other programs that will reimburse on quality care, the complexity and hassle factor climbs above tolerance for some providers.
Thus the question comes….“How do I opt out of Medicare?”.
Let’s start at the beginning. Why do we need to opt out?
Unlike other third party payers where you must make the effort to enroll, Medicare has a rule that automatically requires you to submit claims for any Medicare Beneficiary who receives covered services from you. It’s called the Mandatory Claim Submission Rule.
Mandatory claim submission rule
The Social Security Act (Section 1848(g)(4)) requires that claims be submitted for all Medicare patients for services rendered on or after September 1, 1990. This requirement applies to all physicians (including NPs) and suppliers who provide covered services to Medicare beneficiaries, and the requirement to submit Medicare claims does not mean physicians or suppliers must accept assignment. Compliance to mandatory claim filing requirements is monitored by CMS, and violations of the requirement may be subject to a civil monetary penalty of up to $2,000 for each violation, a 10 percent reduction of a physician’s/supplier’s payment once the physician/supplier is eventually brought back into compliance, and/or Medicare program exclusion. Medicare beneficiaries may not be charged for preparing or filing a Medicare claim. (1,2)
Enrolling in Medicare means:
- You receive a provider number and billing privileges.
- You agree to abide by medicare’s determination regarding covered services.
- You agree to be paid according to the Medicare allowable schedule and do not balance bill.
- You attest that you are the individual applying for billing privileges (fraud prevention measures)
- And of course, you agree to follow CMS rules.
Be aware, that a physician can be a “non-participating” provider with Medicare. Nurse Practitioners do not have that option. We need to either be a participating provider or a provider who has opted-out of the program.
Thus, as the rules become more complex, many providers, especially those in small solo or group practices no longer wish to participate in Medicare and possibly other third party payers. However, unlike other payers, where you just need to cancel your contracts, with medicare you need to formally opt out.
How to Opt-Out
When you opt out of Medicare you will need to notify your Medicare contractor in writing and enter into a private written contract with any patients who are Medicare Beneficiaries.
- Contact your Medicare contractor. They may have the documents you need to opt-out. To my knowledge, there is not an online option for opting out. You’ll need to print out the form, or create it from the verbiage they give you and mail it in. My advice: Never mail anything to Medicare or a Medicare Contractor without a signature receipt and tracking.
- Create a private contract with each Medicare Recipient that you will be treating. Your contractor may have the form you can use, or at least they will give you the language they want you to use.
- Your patients need to clearly understand that you will not bill Medicare, and they cannot submit bills for reimbursement with Medicare. Furthermore, chances are that they will not be able to utilize any secondary insurance to cover the cost of seeing you.
- Be aware, you cannot opt out for some patients and bill Medicare for others.
- Keep a copy of all of the documentation, including your opt-out affidavit and your individual patient contracts.
FAQs about Opting Out
- You can order diagnostic testing for your patients and it will be covered by Medicare if the provider doing the diagnostic testing is an enrolled Medicare provider.
- Once you opt out, it applies to all locations you work. So if you have your own practice, and also work for someone else, they cannot bill Medicare for the services you provide.
- Your private contracts with patients have to be written in a language, using words they understand. For best results, use large fonts and simple, everyday language. This is no place for legal or medical jargon.
- You must file at least 30 days prior to the first day of the calendar quarter (the effective date). You cannot provide services via a private contract until after the effective date.
- Providers who can opt out of Medicare include NPs, CNS’, CRNAs, CNMs, PAs, MDs, DOs, DDS, DPM, ODs, clinical psychologists, clinical social works and registered dietitians and nutritional professionals.
Who is your Medicare Contractor?
If you are unsure who is your contractor, here is the Medicare Fee for Service Provider Enrollment Contact List.
- https://www.ssa.gov/OP_Home/ssact/title18/1848.htm Payment for Physician’s Services (that includes all qualified providers, ie NPs)
Have you opted out Medicare? What challenges did you have?