Are you familiar with Medicare Opt Out Affidavits from the Centers for Medicare and Medicaid Services (CMS)? The Medicare Opt Out list is comprised of physicians, practitioners who do not wish to enroll in the Medicare program. It’s important for your organization to not include any of these individuals in billing to avoid errors and claims that cannot be processed. In this quick guide, we will take a look at how to reference the Medicare Opt Out list, and provide a solution for actively updating your information.

CMS Medicare Opt Out Affidavits

If a physician or provider decides to not be included in the Medicare program, they must submit an affidavit to the Centers for Medicare and Medicaid Services (CMS). Providers may also choose to order or refer services to Medicare beneficiaries who would otherwise submit claims to Medicare Administrative Contractors (MACs). Once a request has been made, neither the physician/practitioner or beneficiary submits a bill for services to Medicare.

A private contract is signed between the physician and the beneficiary which states that neither party can receive payment from Medicare for the services that were performed. Instead, in most circumstances, the beneficiary will pay for the services out-of-pocket.

According to Section 106 (a)(2) of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, the list of practitioners and physicians who choose not to receive payment from Medicare is required to be made available to the public. Information on these providers is published through the Provider Enrollment, Chain, and Ownership System (PECOS) from CMS, and is updated monthly.

CMS PECOS Medicare Opt Out

To gather the full scope of Medicare Opt Out, you can find more information in Section 40 of the Medicare Benefit Policy Manual.

How do Physicians or Practitioners Opt Out of Medicare?

A written affidavit must be sent from the practitioner or physician to CMS and their MAC to express their intention to opt out, and make all billing departments aware of this change. Currently, there is no standardized affidavit form from CMS, but most Medicare Administrative Contractors (MACs) provide a form on their website. Locate your MAC from the following Medicare Fee-for-Service Enrollment Contact List.

If you are a provider who is currently reviewing the opt out process from the Medicare program, take a look at how to go about doing so from this Medicare Learning Network article. The document, supplied by CMS, provides great detail on which types of healthcare professionals are permitted to effectively remove services from being reimbursed through Medicare.

The opt out period begins once the affidavit is signed by the physician or practitioner as long as all procedures are covered, including contracting and form submissions. Once the opt out period begins, it lasts for two years and cannot be terminated unless it is the first time requested by the provider and no later than 90 days after the effective date.

Affidavits submitted after June 16, 2015 do not require a file submission to be renewed after the opt out period ends. However, if the physician or practitioner changes their mind, they may cancel their status once they’ve notified all Medicare contractors and filed an affidavit in writing 30 days prior to the next two year opt out period.

Who is Eligible to Opt Out of Medicare?

Physicians

  • Doctors of medicine or osteopathy
  • Doctors of dental surgery or dental medicine
  • Doctors of podiatry
  • Doctors of optometry
  • Doctors of dental surgery or dental medicine
  • Providers who are legally authorized to practice dentistry, podiatry, optometry, medicine, or surgery by the State in which such function or action is performed

Practitioners

  • Physician Assistants
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Nurse Midwives
  • Clinical Psychologists
  • Clinical Social Workers
  • Certified Registered Nurse Anesthetists
  • Registered Dietitians or Nutrition Professionals
  • Providers who are legally authorized to practice by the state and otherwise meet Medicare requirements

Opt Out Providers Who May Order and Certify Items and Services

It is important to note that there is a significant difference between providers who are permitted to opt out and those who opt out and elect to order and certify items or services. The following physicians and non-physician practitioners are permitted to order and certify:

  • Physicians (doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery, doctor of podiatric medicine, doctor of optometry, optometrists) may only order and certify: DMEPOS products/services and laboratory and X-Ray services payable under Medicare Part B)
  • Physician Assistants
  • Clinical Nurse Specialists
  • Nurse Practitioners
  • Clinical Psychologists
  • Interns, Residents, and Fellows
  • Certified Nurse Midwives
  • Clinical Social Workers

CMS also highlights various limitations on certain providers and types of facilities or services, including chiropractors, home health agencies (HHA), certain Residents, etc. To verify if any limitations apply to your situation, please review the CMS Medicare Opt Out document. The Centers for Medicare and Medicaid Services (CMS) provides great insight and review of the statutes and regulations but provides a disclaimer to not misinform those who intend on investigating the process further.

* DISCLAIMER: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary.

It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2012 American Medical Association.

How to Automate Medicare Opt Out Verification

On a monthly basis, healthcare organizations must pull information from PECOS to verify that no network providers or employees are currently on the Medicare Opt Out list and receiving Medicare reimbursement. ProviderTrust helps automate this process and provide timely notifications if any issues arrive in potential or verified matches.

As you can imagine, we often hear from healthcare professionals about some of the challenges they have with obtaining, referencing, and applying data given by a multitude of government registries and restrictive lists. The Medicare Opt Out list is one of the many sources that we check to ensure compliance and update your provider or claims data on an ongoing basis.

Government Healthcare Data Inefficiencies

With so many connection points that need to be made when it comes to federal healthcare programs, keeping up with many sources of information and organizational compliance tasks can be overwhelming. Further, most of these databases do not contain the same information or report at different times. We’ve made it our mission to step into the data gaps and build some common ground.

Our team has built a collection of automated solutions to help address these data concerns as they pertain to monitoring provider credentials, sanctions screening, claims accuracy for health plans, healthcare vendor engagement, and more. Our goal is to help partner with healthcare organizations to include and support the best providers to deliver excellent patient care.

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ProviderTrust Mike Rosen Cofounder

Written by Michael Rosen, Esq.

ProviderTrust Co-Founder, mrosen@providertrust.com

Michael brings over 20 years of experience founding and leading risk mitigation businesses, receiving numerous accolades such as Inc. Magazine’s Inc. 500 Award and Nashville Chamber of Commerce Small Business of the Year.

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