OPTING OUT OF MEDICARE – WHAT DO I NEED TO KNOW?

December 21, 2022
by Admin

OPTING OUT OF MEDICARE – WHAT DO I NEED TO KNOW?

All Medicare beneficiaries have the right to choose their own doctors and other healthcare providers. But if you are a physician who has opted out of the Medicare program, there are a few things you should know.

First of all, what does it mean to opt out of Medicare? Essentially, it means that a physician has chosen not to participate in the Medicare program and has opted out of Medicare. This means that they are not required to accept Medicare assignment, which is the amount that Medicare pays for a covered service. Instead, they can charge the patient, the Medicare beneficiary, more than the Medicare-approved amount for a covered service.

Great news right?  You can charge what you want ??! However there is a caveat lining to this path to cashflow so reader beware.

Medicare Opt Out physicians are required to provide a written agreement to the patient stating that they will not charge a patient more than the Medicare limiting charge for the service. So what is the Medicare limiting charge, you ask? It’s the maximum amount that a Medicare Opt Out physician can charge a Medicare beneficiary for a covered service. It’s equal to the Medicare fee schedule amount for the service, plus an additional amount determined by the physician

In other words, even though Medicare Opt Out physicians can charge patients more than the Medicare-approved amount for a covered service, they MUST provide proper documentation to be protected from a regulatory standpoint.

Do keep in mind, this is DIFFERENT from a non-par provider, who is indeed limited by said limiting charge.

So, if you’re considering becoming a Medicare Opt Out physician, just be sure to have that written agreement handy and make sure you understand the terms before you agree to provide care to a Medicare beneficiary. 

Want to read the fine print?  No sweat…here’s the link to the manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs

Not asleep yet? Try this: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf.

Section 40.5 on page 27 is where you’ll want to start you glutton for punishment you…


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