Wiki Provider opting out of Medicare network-reimbursement question

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staciastewart

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If a provider who previously was in network with Medicare decides to opt out of being in network does he get any reimbursement for services through Medicare? He was told by a few other providers that he would still submit to Medicare-which will deny for OON, however there is a form that the patient then submits to Medicare with statement and payment is mailed directly to the patient (which the patient would then reimburse the Dr.). Has anyone heard or dealt with this situation before?

The other part of the question was that the Dr. believes he would receive payment from supplemental policies as well. (so far he has not as they follow Medicare guidelines so if Medicare does not pay/the secondary will not either).

If anyone has worked with this before and can provide any insight into this it would be greatly appreciated.
Thank you,
 
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Medicare does not have a 'network' in the same sense that a commercial insurance plans do. What you're describing sounds more like what happens when a provider chooses not to accept assignment, which is different from opting out of Medicare. Under certain circumstances, a provider may elect to not accept assignment from Medicare, in which case claims must still be submitted to Medicare, but Medicare will make the payment directly to the patient. The provider may collect payment from the patient and/or the secondary payer, up to the Medicare limiting charge, which is usually 115% of the Medicare fee schedule.
 
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