Private Contracts - Medicare

Medicare permits a physician or practitioner to relinquish any Medicare payment for a period of two years and "opt out" of Medicare to enter into private contracts with individual Medicare beneficiaries. This provision of the Medicare Rules became effective July 1, 1998.

Definition

For purposes of this Medicare provision, "physician" that are eligible to opt out from Medicare is limited to doctors of medicine, doctors of osteopathy, doctors of dental surgery or dental medicine, doctors of podiatric medicine, and doctors of optometry. Chiropractors and any specialty not eligible to enroll in Medicare are providers that are not eligible to opt out of Medicare.

"Practitioner" that are eligible to opt out from Medicare is limited to physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, clinical psychologists, clinical social workers, registered dieticians, and nutrition professionals. Anesthesiologist assistants, physical therapists, occupational therapists and speech language pathologists are practitioners that are not eligible to opt out of Medicare.

Scope

When a physician or practitioner opts out of Medicare, no services provided by that physician or practitioner are covered by Medicare. Additionally, a physician or practitioner cannot choose to opt out of Medicare for some beneficiaries but not for others, or for some services but not for others

No Medicare payment can be made to the physician or practitioner either directly or on a capitated basis. Likewise, no Medicare payment can be made to a beneficiary for items or services provided directly by the physician or practitioner who has opted out of Medicare.

Covered services ordered by a physician or practitioner who has opted out of Medicare may be payable only when the physician or practitioner has acquired a Medicare unique provider identification number (UPIN) and the services are furnished by another physician or practitioner who has not opted out of Medicare. For example, if an "opt out" physician admits a Medicare beneficiary to a hospital, Medicare will reimburse the hospital for covered services.

In an emergency or urgent care situation, a physician or practitioner who opts out of Medicare may treat a Medicare beneficiary with whom he or she does not have a private contract. However, the physician or practitioner may not charge the Medicare beneficiary more than the amount a non-participating physician would be permitted to charge. The physician or practitioner must submit a claim to Medicare and the payment will be made for covered items or services furnished in an emergent or urgent situation only when the beneficiary has not signed a private contract with the treating physician or practitioner.

Reference

https://med.noridianmedicare.com/web/jeb/enrollment/opt-out

Revision History