September 24, 2015
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When a Doctor Opts Out of Medicare
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When a Doctor Opts Out of Medicare
by Vicky Major-Bell

Did you know that doctors are required to tell a patient up-front that they have opted out of Medicare? 

They are required to give the patient a formal “contract” prior to receiving services. An example of a contract is provided below.

This agreement is between Dr._____________________ (“Physician”), whose principal place of business is __________________, and patient __________________(“Patient”), who resides at ____________________ and is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997.  The Physician has informed Patient that Physician has opted out of the Medicare program effective on _______________ for a period of at least two years, and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.

Technically, without prior research on a policyholder’s part, a patient will not know until they get to the doctor’s office that the doctor does not accept Medicare, because they are not required to inform patients by phone or during the initial scheduling of appointments unless asked. I would believe that most doctor’s offices would verify insurance and the subject would come up, but you never know.

Patients should always ask their doctor if he/she accepts Medicare before they get care. The doctors could either accept Medicare (PAR), is a non-PAR physician (where they still file, but there is an excess charge) or do not accept Medicare. In addition, they can learn whether their doctor accepts Medicare and takes assignment by going online and visiting http://www.medicare.gov/physiciancompare/.

Doctors who have applied to be part of the opt-out program in the past had to renew every two years however, now a doctor who participates in the opt-out program as of April of 2015 does not have to renew anymore (Medicare Access and CHIP Reauthorization Act of 2015).

Opt-out doctors are doctors who have formally opted out of the Medicare program. Opt-out doctors can charge their Medicare patients whatever they want. These doctors do not submit any bills (medical claims) to Medicare and are not subject to the Medicare law that limits the amount doctors may charge patients.

  • If patients see an opt-out doctor, they pay the entire cost of their care (except in emergencies). The doctor should have the patient sign a private contract that states that they understand they are responsible for the full cost of the services. Medicare will not pay for any of the cost of services you receive from an opt-out doctor.
  • Note that psychiatrists are more likely than any other type of provider to opt out of Medicare.

So in other words…yes a doctor has to submit it to their patients in writing and they have to acknowledge that they understand in no way will Medicare be involved in paying the services provided by that physician. Which means the supplement would not do the policyholder any good in that specific situation.

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