Ophthalmology and Optometry Coding Alert

Opting Out of Medicare? 13 Essentials for Private Contracts

Published on Thu Oct 07, 2004

Follow Medicare's rules to leave Medicare behind

Before you opt out of Medicare, make sure you know how to enter into contracts with each of its patients, or you'll be dealing with more trouble than you can shake a denied claim at.

To ensure you're on the right side of Medicare's rules, follow this checklist of 13 top patient contract must-haves, according to section 3044.8 of the Medicare Carriers Manual. The contract should:

Be in writing and in print large enough for the beneficiary to read the contract.

Identify whether the physician is excluded from Medicare.

State that the beneficiary agrees not to submit a claim to Medicare or ask the physician to submit a claim to Medicare.

Specify that the beneficiary understands that Medicare limits do not apply to what the physician may charge for items or services the physician furnishes.

Ensure that the beneficiary understands that Medicare payment will not be made for any items or services the physician furnishes that Medicare would have covered if there was no private contract, and if you'd submitted a proper Medicare claim.

State that the beneficiary enters into the contract knowing that he has the right to obtain Medicare-covered items and services from physicians who have not opted out of Medicare.

Include the expected or known effective date and expected or known expiration date of the opt-out period.

State that the beneficiary understands that Medigap plans do not - and that other supplemental plans may elect not to - make payments for items and services Medicare doesn't reimburse.

Have the beneficiary's and the physician's signature.

Not be entered into by a beneficiary who requires emergency or urgent-care services.

Be provided to the beneficiary before the physician provides items or services under the contract's terms.

Be retained by the physician for the duration of the opt-out period.

Be made available to CMS upon request, and entered into for each opt-out period.