Question Medicare opted out provider

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Elmhurst, NY
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My cardiologist office opted out of Medicare but there are 3 participating providers in that practice that takes these commercial insurances like BC/BS, Aetna, Cigna, UHC and Oxford secondary. Our office is accepting assignment with Medicare because of the participating secondary carrier. We are getting denials from the secondary insurance that there's no patient responsibility after Medicare denial. When we are submitting our claims, do we accept assignment on the claim so we can submit to secondary assigned as a primary carrier or do we not accept assignment because we opted out of Medicare so Medicare leaves a patient responsibility to submit to participating secondary carrier unassigned and process as primary carrier. Please help us in what we are doing wrong.
 

thomas7331

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I think you should probably have your practice's compliance officer or legal counsel review this - opting out of Medicare can be a complex issue and can have legal consequences if not properly followed. Normally, as I understand it, if a provider has opted out of Medicare, then they should only be seeing Medicare patients with whom they have a written private contract, and in those cases, no claims should be filed to Medicare. Patients would be responsible for the payment to this provider in full. I don't believe an opt-out provider can selectively file some claims to Medicare just for the purposes of obtaining patients' secondary payments. If your practice has filed claims to Medicare for this provider, then they may have inadvertently nullified this provider's opt-out status, and there may be legal and financial repercussions involved. Have someone review this who understands the laws and can ask the appropriate and detailed questions as to what has happened and give you sound advice.
 

SharonCollachi

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Clovis, CA
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My cardiologist office opted out of Medicare but there are 3 participating providers in that practice that takes these commercial insurances like BC/BS, Aetna, Cigna, UHC and Oxford secondary. Our office is accepting assignment with Medicare because of the participating secondary carrier. We are getting denials from the secondary insurance that there's no patient responsibility after Medicare denial. When we are submitting our claims, do we accept assignment on the claim so we can submit to secondary assigned as a primary carrier or do we not accept assignment because we opted out of Medicare so Medicare leaves a patient responsibility to submit to participating secondary carrier unassigned and process as primary carrier. Please help us in what we are doing wrong.
Groups/organizations cannot opt out of Medicare, only individuals can. I am guessing that is what you meant.

Medicare clearly states: If a provider has elected to Opt Out of Medicare, they cannot bill for any current patients or clients for any reason except for emergency situations.

Since you can only see patients with a signed private contract, and that contract states neither you nor they can bill Medicare... then what are you doing?? Your contract should included what happens with secondary insurances. Noridian Medicare's sample contract (click me for link) states, "I (the patient) understand that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare."

I would stop billing Medicare immediately; I'm surprised they have not sent you a letter to that effect.
 
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