Medicare Compliance & Reimbursement

So, you've decided to no longer participate in the Medicare program -- but chances are you'll still face your share of payer red tape.

If your practice includes non-par providers or physicians who have opted out of Medicare, it's a good bet that your doctors will eventually treat a Medicare beneficiary. Sometimes this is due to a patient having an emergency and rushing to your office because it's nearby, or it may occur when a current patient ages into Medicare and forgets to tell you that her insurer changed from a private plan to Part B.

The good news: CMS recently issued Transmittal 1557 (http://www.cms.hhs.gov/transmittals/downloads/R1557CP.pdf), which indicates that under certain circumstances, carriers will process claims that beneficiaries self-submit to Medicare.

The bad news: The new transmittal doesn't change the fact that non-par providers must submit claims to the carrier on the patient's behalf (and that those who have opted out cannot bill Medicare). The transmittal notes that it will keep track of each "provider or supplier that refuses to submit a claim on the beneficiary's behalf," and that it will keep a list of the "top 50 violators, by state, of the mandatory claim submission policy."

Non-participating providers must file claims to Medicare, and they'll collect the limiting charge. On the other hand, if you have opted out of the Medicare program, you privately contract with Medicare patients and you do not have to submit claims to Part B for their care.

Here's how: A practice that has opted out of Medicare may agree to treat a Medicare patient on a non-emergent basis, on the condition that the patient will not file the claim to Medicare. If a doctor opts out of Medicare, he can enter into a written contract, signed by the patient, stating that the physician will not file the claim with Medicare and the patient won't do so either.

Caveat: Even if a practice opts out of Medicare for non-emergent procedures, the physician can still see patients on an emergency basis, but they have to submit those claims to Medicare on the patient's behalf for the emergency procedures, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, with CRN Healthcare Solutions in Tinton Falls, NJ.