(Medicare Benefit Policy Manual)

40.15 - Excluded Physicians and Practitioners  (Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)  An excluded physician or practitioner may opt out of Medicare by submitting the required documentation in accordance with 40.9 .  When determining effective dates of the exclusion versus the opt-out, the date of exclusion always takes precedence over the date the physician or practitioner opts out of Medicare.  A physician or practitioner who has been excluded must comply with 42 CFR 1001.1901 , Scope and Effect of Exclusion.  If an excluded/opt- out physician or practitioner submits a claim to Medicare, the Medicare contractor must not make payment for services furnished, ordered, or prescribed on or after the effective date of the exclusion, except in the limited circumstances stated in 42 CFR 1001.1901.  The Medicare contractor must not make payment to a beneficiary who submits claims for services rendered by an excluded/opt-out physician or practitioner (except where payment would otherwise be made in accordance with the Medicare Program Integrity Manual) .  It must deny the claim and send the physician or practitioner the appropriate remittance and send the beneficiary a MSN as explained in 40.39.  40.16 - Relationship Between Opt -Out and Medicare Participation Agreements  (Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)  Participation agreements will terminate on the opt out effective date. See 40.17 for effective date provisions.  Physicians and practitioners may not provide services under private contracts with beneficiaries earlier than the effective date of the affidavit.  Nonparticipating physicians and practitioners may opt out at any time.  The Medicare contractor must update the system files so that it may timely pay participating physicians and practitioners at the correct payment amounts in effect for that part of the fee schedule year before they opt out and to pay them as nonparticipating for emergency or urgent care as of their opt out effective date.   40.17 - Participating Physicians and Practitioners  (Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)  Participating physicians and practitioners may opt out if they file an affidavit that meets the criteria and which is received by the Medicare contractor at least 30 days before the first day of the next calendar quarter showing an effective date of the first day in that quarter (i.e., January 1, April 1, July 1, October 1).  They may not provide services under private contracts with beneficiaries earlier than the effective date of the affidavit.   The 30-day notice is required to allow sufficient time for the Medicare contractor to accomplish the appropriate system file updates before the effective date.  The Medicare contractor must make participating physician status changes no less frequently than at the beginning of each calendar quarter.  Therefore, participating physicians or practitioners must provide the Medicare contractor with 30 days notice that they intend to opt out at the beginning of the next calendar quarter.  Participating physicians or practitioners may sign private contracts only after the effective date of affidavits filed in accordance with 40.9.  They may not provide services under private contracts with beneficiaries earlier than the effective date of the affidavit.  It is necessary to treat nonparticipating physicians or practitioners differently from participating physicians or practitioners in order to assure that participating physicians or practitioners are paid properly for the services they furnish before the effective date of the affidavit.   Participating physicians or practitioners are paid at the full fee schedule for the services they furnish to Medicare beneficiaries.  However, the law sets the payment amount for nonparticipating physicians or practitioners at 95 percent of the payment amount for participating physicians or practitioners.  Participating physicians or practitioners who opt out are treated as nonparticipating physicians or practitioners as of the effective date of the opt -out affidavit.  When a participating physician/practitioner opts out of Medicare, the Medicare contractor must pay the physician/practitioner at the higher participating physician/practitioner rate for services rendered in the period before the effective date of the opt -out; and at the nonparticipating rate for services rendered on and after the opt-out date.  40.18 - Physicians or Practitioners Who Choose to Opt Out of Medicare  (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)  If a physician/practitioner chooses to opt-out of Medicare, it means that the physician/ practitioner opts-out for all covered items and services that he or she furnishes.  Physicians and practitioners cannot have private contracts that apply to some covered services they furnish but not to others.  For example, if a physician or practitioner provides laboratory tests or durable medical equipment incident to his or her professional services and chooses to opt-out of Medicare, then the physician/practitioner has opted out of Medicare for payment of lab services and Durable Medical Equipment, Prosthetics, and Orthotics (DMEPOS) as well as for professional services.  If a physician or practitioner has a valid opt-out affidavit on file with the MAC, has a valid NPI, is a specialty that is eligible to order or certify, and refers a beneficiary to a non-opt-out physician or practitioner for medically necessary services, such as laboratory, DMEPOS or inpatient hospitalization, Medicare would cover those services.  In addition, because suppliers of DMEPOS, independent diagnostic testing facilities, clinical laboratories, etc., cannot opt-out, the physician or practitioner owner of such suppliers cannot opt-out as such a supplier.  Therefore, the participating physician or practitioner becomes a nonparticipating physician or practitioner for purposes of Medicare payment for emergency and urgent care services on the effective date of the opt-out.  (See 40.28).  40.19 - Opt-Out Relationship to Noncovered Services (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08 -15-16)  Because Medicares rules do not apply to items or services that are categorically not covered by Medicare, a private contract is not needed to furnish such items or services to Medicare beneficiaries, and Medicares claims filing rules and limits on charge s do not apply to such items or services.  For example, because Medicare does not cover hearing aids, a physician or practitioner, or other supplier may furnish a hearing aid to a Medicare beneficiary and would not be required to file a claim with Medicare; further, the physician, practitioner, or other supplier would not be subject to any Medicare limit on the amount they could collect for the hearing aid.  If the item or service is one that is not categorically excluded from coverage by Medicare, but may be noncovered in a given case (for example, it is covered only where certain clinical criteria are met and there is a question as to whether the criteria ar e met), a non -opt-out physician/practitioner or other supplier is not  relieved of his or her obligation to file a claim with Medicare.  If the physician or practitioner or other supplier has given a proper Advance Beneficiary Notice (ABN), he or she may collect from the beneficiary the full charge if Medicare does deny the claim.   Where a physician or practitioner has opted out of Medicare, he or she must provide covered services only through private contracts that meet the criteria specified in 40.8 (including items and services that are not categorically excluded from coverage but may be excluded in a given case).  An opt-out physician or practitioner is prohibited from submitting claims to Medicare (except for emergency or urgent care services furnished to a beneficiary with whom the physician or practitioner did not have a private contract).  (See 40.12 .)  40.20 - Maintaining Information on Opt -Out Physicians  (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)  The Medicare contractor must maintain information on the opt-out physicians or practitioners.  At a minimum, it must capture the name and TIN of the physician or practitioner, the effective date of the opt-out affidavit, and the automatic 2- year renewal date for affidavits filed on or after June 16, 2015.  If the physician/practitioner cancels opt- out (see 40.34), then the Medicare contractor must also maintain the physician/practitioners opt -out end date or cancellation date.  The Medicare contractor may also include other provider -specific information it may need.  If cost effective, it may house this information on its provider file.   40.21 - Informing Medicare Managed Care Plans of the Identity of the Opt -Out Physicians or Practitioners (Rev. 222, Issued: 05- 13-16, Effective: 08 -15-16, Implementation; 08- 15-16)  The Medicare contractor must develop data exchange mechanisms for furnishing Medicare managed care plans in its service area with timely information on physicians and practitioners who have opted out of Medicare.  For example, it may wish to establish an I nternet website Home Page which houses all of the information on physicians or practitioners who have opted out.  It will need to negotiate appropriate opt -out information exchange mechanisms with each managed care plan in its service area.   40.22 - Informing the National Supplier Clearinghouse (NSC) of the Identity of the Opt-Out Physicians or Practitioners  (Rev. 160, Issued: 10- 26-12, Effective: 01 -28-13, Implementation: 01- 28-13)  The Medicare contractor must notify the NSC directly with timely information on physicians or practitioners who have opted out of Medicare.  An Internet Web site Home Page is not an acceptable means of notifying the NSC.  The NSCs address is as follows:   National Supplier Clearinghouse  P.O. Box 100142 Columbia, SC 29202- 3142  40.23 - Organizations That Furnish Physician or Practitioner Services  (Rev. 1, 10- 01-03) B3-3044.23  The opt -out applies to all items or services the physician or practitioner furnishes to Medicare beneficiaries, regardless of the location where such items or services are furnished.   Where a physician or practitioner opts out and is a member of a group practice or otherwise reassigns his or her rights to Medicare payment to an organization, the organization may no longer bill Medicare or be paid by Medicare for services that the physic ian or practitioner furnishes to Medicare beneficiaries.  However, if the physician or practitioner continues to grant the organization the right to bill and be paid for the services the physician or practitioner furnishes to patients, the organization may bill and be paid by the beneficiary for the services that are provided under the private contract.  The decision of a physician or practitioner to opt out of Medicare does not affect the ability of the group practice or organization to bill Medicare for t he services of physicians and practitioners who have not opted out of Medicare.  Corporations, partnerships, or other organizations that bill and are paid by Medicare for the services of physicians or practitioners who are employees, partners, or have other arrangements that meet the Medicare reassignment -of-payment rules cannot opt out because they are neither physicians nor practitioners.  Of course, if every physician and practitioner within a corporation, partnership, or other organization opts out, then such corporation, partnership, or other organization would have, in effect, opt ed out.   40.24 - The Difference Between Advance Beneficiary Notices (ABN) and Private Contracts  (Rev. 1, 10- 01-03) B3-3044.24  An Advance Beneficiary Notice (ABN) allows a beneficiary to make an informed consumer decision by knowing in advance that the beneficiary may have to pay out-of-pocket.  An ABN is not needed where the item or service is categorically excluded from Medicare coverage or outside the scope of the benefit.   An ABN is used when the physician/practitioner believes that Medicare will not make payment, while private contracts are used for services that are covered by Medicare and for which payment might be made if a claim were to be submitted.   See the Medicare Claims Processing Manual, chapter 30, for a description of the ABN.  40.25 - Private Contracting Rules When Medicare is the Secondary Payer  (Rev. 1, 10-01-03) B3-3044.25  The opt- out physician/practitioner must have a private contract with a Medicare beneficiary for all Medicare- covered services (see 40.7), notwithstanding that Medicare would be the secondary payer in a given situation.  No Medicare primary or  secondary payments will be made for items and services furnished by a physician/practitioner under the private contract.