Medicare Compliance & Reimbursement

Understand the out-of-network payment option.

Question: Our orthopedic practice sees primarily pediatric patients at a children’s hospital, and therefore we are not enrolled with Medicare. However, we have one patient who we thought only had Medicaid, but it turns out has Medicare as well. Since we aren’t enrolled with Medicare, we cannot bill Medicare to get a denial, and Medicaid will not process the claim without the Medicare denial. Can you help?

Codify Subscriber

Answer: You absolutely can file the claim with Medicare, but you’ll be paid as an out-of-network provider, so just like with any other payer, the patient’s responsibility will be higher in this case. First, however, confirm that the physician himself isn’t enrolled in Medicare — some physicians are and don’t even realize it, especially if they came from a large, multi-specialty practice or if they saw adult patients in their previous orthopedic practice.