Can non-Medicare therapists see Medicare clients, or can Medicare clients get reimbursed?  I’m not a Medicare expert, so I’ve journeyed once again to the feet of my favorite Medicare guru Susan Frager, veteran biller, Medicare specialist, and owner of  PsychBillingCoach.com Here’s the deal, says Frager:

If you are a MFT, counselor, LCSW, or psychologist, you are eligible to participate in Medicare as a provider.   So you’ll need to decide if you want to enroll as a Medicare provider.  If not, you’ll need to officially opt-out if you want to see Medicare clients in your practice and accept direct payments from the client.

Unlike other private health plans, where you can just choose not to do anything and you will automatically be considered an out-of-network provider, with Medicare you have to file a formal Opt-out Affidavit in writing stating that you do not want to participate.   You must enroll in or opt out of Medicare before you can accept money from a Medicare client in your practice.  If you don’t, Medicare could force you to refund any money paid to you by a Medicare client.

However, before opting out, there are some things to consider.  

If you are a network provider with other insurance plans, carefully check your provider contracts or call the health plan before opting out of Medicare.  The contract you signed may have required you to remain in-network with Medicare so you can provide services to their Medicare members.  At least one clinician reported her Blue Cross Blue Shield contract was terminated when they found out she had opted out of Medicare.  Another reported her Kaiser contract was terminated.

Also, keep in mind that opting-out can make it difficult to find a job at an agency, hospital,  or group practice that accepts Medicare.   This is because once you opt out, you are opted out at all sites where you work. You can’t accept Medicare at one location and not do so at another.  Since the Opt-Out is good for two years, this can be a 2 year obstacle.  

The steps to opting-out:

1. Determine who administers the Medicare contract in your area, also known as the Medicare Administrative Contractor (MAC).  This list can be found here

2. Once you see what MAC administers the Medicare contract in your area, do an online search for their Opt Out document.  For example, enter the name of the MAC in your search engine and then the words Opt Out Affidavit (ex. Noridian Opt Out Affidavit).  You an also to go to the MAC’s website by searching for the name of the MAC (ex.”Noridian Medicare”).  On the home page, look under Part B for “Provider Enrollment.”  Then click on “Opt Out of Medicare” and you should find both the Affidavit (to Opt Out) and possibly, the Private Contract (which we will talk about next).

3.  “It usually takes about 30 days for the opt out affidavit to be accepted,” says Frager, but she admits it would be no surprise if the Medicare folks take longer.

Important Next Step

If you opt-out and want to see the Medicare client, you will then need to set up a Private Pay Contract with them.   Some MACs have a sample private contract on their site.  

Search the internet as instructed above for a Medicare Private Pay Contract to use by entering the name of your Medicare MAC and the words Private Pay Contract.  However, not all MACs have their own Sample Private Pay Contract.  “I highly recommend that you use one of the Medicare downloadable forms, even if it’s from a different Medicare contractor,” says  Frager.  You can always use this one from Noridian if your contractor doesn’t have one.  

“What people don’t realize is that Medicare can audit compliance with private contracts, and if your contract doesn’t exactly say everything that they want, if it isn’t done the way they want it, in the timeframes they want it, then they can force you to refund your private-pay client,” says Frager.  “If you were previously enrolled, they can cancel your opt-out. If you were never enrolled, then you’ll have to enroll in order to file claims.”

Some helpful resources:

• Here is a list of rules about the Private Contract:  click here
• If you click here you will find a list of providers who have opted out of Medicare.  You might want to check for your name on the list once you have opted-out.
• Frager is a great resource for Medicare questions.  She has helpful webinars to help you decide if you want to participate, and she can provide enrollment or opt-out assistance.  You can contact her at PsychBillingCoach.com