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Reader Question:

Opt Out of Trouble When You Opt Out of Medicare

Published on Thu May 01, 2003

Question: Our physicians have decided to no longer accept Medicare patients. Our office has taken care of the requisite measures by filing an affidavit with Medicare and preparing for the two-year commitment. Our billing office is in charge of checking over the patient contracts before we send them out. What should we make sure the contracts include?

Kansas Subscriber

Answer: Physicians who decide to opt out of Medicare must enter into private contracts with each of their patients and if your contract isn't just so, it's invalid in Medicare's eyes.

To ensure you're on the right side of the rules, follow this checklist of patient contract must-haves:

According to section 3044.8 of the Medicare Carriers Manual, a private contract between a patient and an opted-out physician must:

  • Be in writing and in print sufficiently large to ensure that the beneficiary is able to read the contract.
  • Clearly state whether the physician is excluded from Medicare.
  • State that the beneficiary or his legal representative agrees not to submit a claim to Medicare or ask the physician to submit a claim to Medicare.
  • State that the beneficiary or his legal representative understands that Medicare limits do not apply to what the physician may charge for items or services furnished by the physician.
  • State that the beneficiary or his legal representative 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 was no private contract, and a proper Medicare claim had been submitted.
  • State that the beneficiary or his legal representative enters into the contract with the knowledge that he has the right to obtain Medicare-covered items and services from physicians who have not opted out of Medicare, and that the beneficiary 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.
  • State the expected or known effective date and expected or known expiration date of the opt-out period.
  • State that the beneficiary or his legal representative understands that Medigap plans do not and that other supplemental plans may elect not to make payments for items and services not paid for by Medicare.
  • Be signed by the beneficiary or his legal representative and by the physician.

  • Not be entered into by the beneficiary or by the beneficiary's legal representative during a time when the beneficiary requires emergency care services or urgent care services.
  • Be provided to the beneficiary or his legal representative before items or services are furnished to the beneficiary under the terms of the contract.
  • Be retained by the physician/practitioner for the duration of the opt-out period.

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

    You Be the Expert and Reader Questions were reviewed by Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc. in Spring Lake, N.J.

     

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