Chiropractic Coding & Compliance Alert

Reader Questions:

When Can an "Opt out" Provider Treat a Medicare Patient?

Published on Fri Jun 12, 2015

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Question: When a physician or practitioner opts out of Medicare; can he still get reimbursement for treating Medicare patients?

Wisconsin Subscriber

Answer: When a physician/practitioner opts out of Medicare, Medicare covers no services provided by that individual and no Medicare payment can be made to that physician or practitioner directly or on a capitated basis. Additionally, no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program.

However, payment will be made for Medicare covered items or services furnished in emergency or urgent situations when the beneficiary has not signed a private contract with that physician/practitioner.

Medicare will make payment for covered, medically necessary services that are ordered by a physician/practitioner who has opted out of Medicare if the ordering physician/practitioner has acquired a National Provider Identifier (NPI) and provided that the services are not furnished by another physician/practitioner who has also opted out. For example, if an opt-out physician/practitioner admits a beneficiary to a hospital, Medicare will reimburse the hospital for medically necessary care. The physician/practitioner may not charge the beneficiary more than what a nonparticipating physician/practitioner would be permitted to charge and must submit a claim to Medicare on the beneficiary’s behalf.