Opt Out of Medicare

How To Opt Out of Medicare as a Physician and Should You?

Opt Out of MedicareIf you are considering opting out of Medicare, or wondering why anyone would, I suggest you read the entire article, highlighted below, first.

An excerpt from “Opting Out of Medicare: A Very Rational Decision” by Mary Jo Curran, MD

The decision to opt out of Medicare is straightforward and easy, once you analyze the risks, costs, and benefits of taking part in this federal government entitlement program.  As with any such program, someone must pay for it.  The axiom popular in 1960s economics circles and quoted by Milton Friedman in 1976 at his Nobel Prize acceptance speech, is a reality.  The Medicare program has been likened to a Ponzi scheme. Current Medicare recipients take much more out of the system than they ever put  into it.

Taxpayers, doctors, and hospitals now share the enormous cost, but when this becomes impossible to bear, Medicare as we know it will no longer exist. There are a number of easons to opt out before the program.s ultimate demise. After moving our billing service inhouse and no longer using an outside source, it became quickly apparent that in my practice Medicare claims were a huge problem. Not only was it difficult to get paid; many procedures were disallowed as being not ‘medically necessary’ although clearly beneficial to patients In making such determinations, the government is essentially practicing medicine without a license. The decisionmaker is certainly not a  physician boardcertified in pain medicine and frequently is a clerk with minimal education. To be sure, there is associated with the Medicare carrier, but this doctor has no training in my field of expertise.

If you think you would like to opt out, here is the process, courtesy of AAPS:

IF YOU ARE A NON-PARTICIPATING PHYSICIAN, then opting out is as follows: Step One: Notify your patients that you are opting out of Medicare.Step Two: File a copy of the following affidavit with “each carrier that has jurisdiction over the claims that the physician or practitioner would otherwise file with Medicare.” (quoting CMS Qs and As on Private Contracts, #10). The addresses will vary depending on the region of the country in which you practice. Click here for a list of Medicare carriers by state. The affidavit should be equivalent to the following:I, ______, declare under penalty of perjury that the following is true and correct to the best of my knowledge, information, and belief:1. I am a physician licensed to practice medicine in the state of ______. My address is at _________, my telephone number is _________, and my [national provider identifier (NPI) or billing number, if one has been assigned, uniform provider identification number (UPIN) if one has been assigned, or, if neither an NPI nor a UPIN has been assigned, my tax identification number (TIN)] is _________. I promise that, for a period of two years beginning on the date that this affidavit is signed (the “Opt-Out Period”), I will be bound by the terms of both this affidavit and the private contracts that I enter into pursuant to this affidavit. [NOTE: Your personal UPIN number must be used, not a corporate UPIN number. Persons opt out, not corporations.]2. I have entered or intend to enter into a private contract with a patient who is a beneficiary of Medicare (“Medicare Beneficiary”) pursuant to Section 4507 of the Balanced Budget Act of 1997 for the provision of medical services covered by Medicare Part B. Regardless of any payment arrangements I may make, this affidavit applies to all Medicare-covered items and services that I furnish to Medicare Beneficiaries during the Opt-Out period, except for emergency or urgent care services furnished to Beneficiaries with whom I had not previously privately contracted. I will not ask a Medicare Beneficiary who has not entered into a private contract and who requires emergency or urgent care services to enter into a private contract with respect to receiving such services, and I will comply with 42 C.F.R. § 405.440 for such services.3. I hereby confirm that I will not submit, nor permit any entity acting on my behalf to submit, a claim to Medicare for any Medicare Part B item or service provided to any Medicare Beneficiary during the Opt-Out Period, except for items or services provided in an emergency or urgent care situation for which I am required to submit a claim under Medicare on behalf of a Medicare Beneficiary, and I will provide Medicare-covered services to Medicare Beneficiaries only through private contracts that satisfy 42 C.F.R. § 405.415 for such services.4. I hereby confirm that I will not receive any direct or indirect Medicare payment for Medicare Part B items or services that I furnish to Medicare Beneficiaries with whom I have privately contracted, whether as an individual, an employee of an organization, a partner in a partnership, under a reassignment of benefits, or as payment for a service furnished to a Medicare Beneficiary under a Medicare+Choice plan, during the Opt-Out Period, except for items or services provided in an emergency or urgent care situation. I acknowledge that, during the Opt-Out Period, my services are not covered under Medicare Part B and that no Medicare Part B payment may be made to any entity for my services, directly or on a capitated basis, except for items or services provided in an emergency or urgent care situation.5. A copy of this affidavit is being filed with [the name of each local Medicare carrier], the designated agent of the Secretary of the Department of Health and Human Services, no later than 10 days after the first contract to which this affidavit applies is entered into. [FOR PARTICIPATING PHYSICIANS ONLY: My Medicare Part B Participation agreement terminates on the effective date of this affidavit.]Executed on [date] by [Physician name]
[Physician signature]

Step Three: Enter into a private contract for, and prior to, rendering any covered services to a Medicare Part B Beneficiary. Such private contract should include the following:This agreement is between Dr. __________ (“Physician”), whose principal place of business is _____________, and patient ____________ (“Patient”), who resides at __________ and is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. The Physician has informed Patient that Physician has opted out of the Medicare program effective on _____ for a period of at least two years, and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.Physician agrees to provide the following medical services to Patient (the “Services”):[LIST ALL THE SERVICES HERE]In exchange for the Services, the Patient agrees to make payments to Physician pursuant to the Attached Fee Schedule. Patient also agrees, understands and expressly acknowledges the following:

  • Patient agrees not to submit a claim (or to request that Physician submit a claim) to the Medicare program with respect to the Services, even if covered by Medicare Part B. 
  • Patient is not currently in an emergency or urgent health care situation. 
  • Patient acknowledges that neither Medicare’s fee limitations nor any other Medicare reimbursement regulations apply to charges for the Services. 
  • Patient acknowledges that Medi-Gap plans will not provide payment or reimbursement for the Services because payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny reimbursement. 
  • Patient acknowledges that he has a right, as a Medicare beneficiary, to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare, and that the patient is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. 
  • Patient agrees to be responsible, whether through insurance or otherwise, to make payment in full for the Services, and acknowledges that Physician will not submit a Medicare claim for the Services and that no Medicare reimbursement will be provided. 
  • Patient understands that Medicare payment will not be made for any items or services furnished by the physician that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim were submitted. 
  • Patient acknowledges that a copy of this contract has been made available to him.[Optional:
  • Patient agrees to reimburse Physician for any costs and reasonable attorneys’ fees that result from violation of this Agreement by Patient or his beneficiaries.]

Executed on [date] by [Patient name] and [Physician name][Patient signature] [Physician signature]

[NOTE to physicians: keep a copy of all of these contracts in case CMS demands them! CMS requires that this contract be re-executed each period.]Step Four: Install procedures to ensure that your office never files a Medicare claim, and never provides information to a patient that enables him to file a Medicare claim. The two exceptions – for emergency or urgent care and for covered services that Medicare would deem unnecessary – should be used with caution.Step Five: Reduce the substantial overhead costs resultant from participating in the Medicare program and being subjected to the Medicare-inspired audits and threats. Then celebrate: you can now spend your time serving patients rather than catering to and being controlled by the government.Step Six: Mark your calendar to send in a new “opt out” affidavit every two years to maintain your status.IF YOU ARE A PARTICIPATING PHYSICIAN, then opting out is as follows:Step One: In the words of CMS: “To opt out of Medicare, a participating physician must first terminate his or her Medicare Part B participation agreement.” (CMS Qs and As on Private Contracts, #5). At the beginning of 1998, CMS only allowed termination of participation on an annual basis. More recently, however, CMS has allowed termination on the following quarterly basis: Jan. 1, Apr. 1, July 1, and Oct. 1. Note, however, that a participating physician must give his or her carrier 30-days’ prior notice by sending in the opt-out affidavit with an effective date of the beginning of the next quarter.Subsequent Steps: Follow the above Steps One through Five for a non-participating physician, except that the physician may not provide private contracting services until the first date of the next quarter that is at least 30 days after receipt of the notice by the carrier. For example, the carrier must receive the notice from the physician by Sept. 1 if the physician seeks to provide private contracting services beginning on Oct. 1. Mark your calendar to send in a new “opt out” affidavit every two years to maintain your status.

More information on Opting Out of Medicare from AAPS

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