Many therapists are still deer-in-headlights, frozen-into-paralysis on how to really make an informed decision of whether to enroll, opt-out, or stay unenrolled with Medicare.

There are a lot of sources online and as with many topics, so much misinformation is tangled in the mix. As insurance experts Barbara Griswold, LMFT, author of Navigating the Insurance Maze, and Susan Frager of PsychBillingCoach point out, not taking any action or making uninformed hasty decisions can lead to significant financial and legal consequences, like having to refund payments or being sanctioned for billing errors.

In these interviews with Barbara and Susan, Gia Reyes LMFT tries to help therapists understand their choices.

Gia: Medicare can be intimidating and confusing, and it does have a bad rap of being full of red tape. Deciding on whether one should enroll, opt-out, or choose not to do anything is very confusing.

Barbara: Right, it can be confusing.  But there are really three choices when it comes to Medicare. Your first option is to “enroll” as a Medicare provider.  This means you can serve the Medicare population and get reimbursed by Medicare. To enroll, you have to go through a very rigorous application process.

Your second option is to “opt out.”  Here you are telling Medicare in a very formal way that you don’t want to work with them.  Unlike private insurance plans, if you don’t want to be involved with Medicare, you have to sign and mail a formal “opt-out” affidavit to your regional Medicare Administrative Contractor, or MAC.  (A list of regional MACs and their contact information and where to send your affidavit can be found here).

The third option is to do nothing (we’ll talk more about this option later).

Gia: What are the ramifications of enrolling vs. opting out?

Barbara:  If you enroll with Medicare, you are able to provide services for the over-age-65 and disabled population, but you have to accept the Medicare discounted rate.   The good news is that Medicare publishes their rates so you can see how much they pay for your services in your city to help make this choice.

You can opt-out, but you might not realize that you just closed a door that really could be a significant source of income for you – Medicare clients.

Every potential client has to be asked if they have Medicare. If they do, and you are a Medicare provider, you must bill Medicare.  If you’ve opted out, you have to make them sign a Medicare Private Pay Agreement that basically says, “I know that Medicare is not going to cover this service, but I still want to see this therapist.”  Many Regional MACs have a Private Pay Agreement you can download, or if you can’t find one, you can use this one.

The Private Pay Agreement is informing your client and getting their consent that they understand they could go see a Medicare provider but are choosing not to, and that they understand they will be paying out-of-pocket.  It also protects you if that client ever files a complaint, because you have proof that you informed the client that this is not going to be reimbursed by Medicare, and you informed them of the ability to go elsewhere.

To see Medicare clients in your private practice, you must have opted out and have that Private Pay Agreement from your client.

You also need to pay attention to clients’ ages.  Many of your clients will “age-in” to Medicare while you are treating them, and you’ll need to have them sign the Agreement.

Here’s where it gets complex:   A lot of clinicians are choosing not to enroll, yet also choosing not to opt out, because some health plans are telling providers that they might be kicked off the provider panel if they opt-out.

Susan: If you are credentialed with some health plans, for example, Kaiser Medicare Advantage, or one of the online platforms like Rula or Grow Therapy, they may require you to NOT opt out. They may say “you don’t need to ENROLL as a provider in Original Medicare, but you CAN’T opt out because we want you to be able to see our Medicare Advantage clients.” I often hear therapists say, “I feel stuck because my insurance contracts are saying I can’t opt out.”  Or the therapist works for another job where they can’t opt out because “my job has to be able to bill Medicare for me.”

Gia: Can a therapist just do nothing, not enrolling and not opting-out?

Barbara: A lot of clinicians don’t want to enroll but are choosing not to opt out because they’re afraid the health plan might kick them off the network. So, they’re weighing the danger and the risk, and doing nothing. They are just flying under the radar by seeing private pay Medicare clients and hoping that Medicare doesn’t find out.  I recommend instead that therapists contact the health plans they work with before opting out to see if there would be any negative consequences.  Many plans are fine with their therapists opting out.

Susan: It is okay to stay unenrolled as long as you follow the rules and don’t see Medicare clients in your private practice. But if a therapist isn’t formally opted out and takes cash from a Medicare client, and Medicare finds out, the therapist will have to refund to the client any amount that was charged that was over the Medicare allowed amount.

If you are not enrolled, you need to make sure that every client you see does not have Medicare. Even more than that, though, you should look at their insurance cards. I mean, I can’t tell you how often a client isn’t clear. They may say they have Aetna, but you could get their card, and you see it says, ‘Medicare Advantage.’ Just about all of the commercial insurance companies offer Medicare Advantage plans.

Gia: What are the basic differences between Medicare and Medicare Advantage?

Susan: When you turn 65, you become eligible for Medicare. You get a choice – sign up for Original Medicare or you can choose to enroll in a Medicare program administered by a private health plan, such as United Healthcare Medicare Advantage, Humana Medicare Advantage, Anthem Medicare Advantage, Kaiser Medicare Advantage, etc.

Original Medicare provides the same benefits for everybody, which is a small deductible each year and then it’s a 20% copayment. With Original Medicare, there’s no such thing as verifying benefits for mental health because they’re always the same. All you have to do is verify eligibility and you look at deductible status. Only about 48% of people with Medicare are enrolled in Original Medicare.

Meanwhile, Medicare Advantage is a hybrid, basically commercial insurance grafted onto Medicare.  If your client has a Medicare Advantage plan, you need to find that out because that means you bill the Advantage plan, not Original Medicare.

Gia: What are the basic factors to consider in making an informed decision on whether to become a Medicare provider?

Barbara:  There are a few things to think about before you opt-out.  If you are a network provider for any insurance plan, contact them or check your contract– you may be required to accept Medicare clients.  I’ve heard of health plans kicking providers off their plans when a provider opted out of Medicare.

Another thing to consider is that many agencies, hospitals, and groups require that their clinicians accept Medicare.  Opting out can limit your job opportunities.

Susan: I don’t believe there’s one right answer.  What kind of community do you practice in? Who are your clients? Are your clients seniors? Are they disabled?  And when we say disabled, we’re not just talking about physically disabled, but mentally disabled too. We’re talking about anybody who receives Social Security disability and gets Medicare through SSDI.

If these are your clients, and if you don’t take Medicare, how are they going to be able to afford your services?

Now if you work with kids, you might choose to opt out.  Because most kids aren’t going to have Medicare until they’re old enough to age out into where they can get disability on their own. So as long as they’re able to be carried under their parents’ policies until age 26, you’re not going to have to worry about Medicare.

If you’re in a really wealthy community, you may have clients able and willing to pay your full fee on a cash basis. But in areas where clients depend on Medicare reimbursement, Medicare may actually pay comparably or more than managed care. Their reputation for being the lowest of the low isn’t always justified. So, you should really consider your geographic location and the demographic you serve.

For more information about your Medicare choices see:

• Susan’s “Opting Out of Medicare” Guide, her courses, and and her article  I Don’t Want to Enroll in Medicare!!!”
• Schedule a consultation with Susan for assistance making this decision, or with enrolling, or check out her other articles here
• Read Barbara’s page stuffed with lot of answers to your  Medicare questions at Barbara’s Medicare Information Page here
• Read Barbara’s other articles on Medicare here

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Barbara Griswold LMFT is a private practice coach and author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – And Whether You Should, now in its 10th edition. Barbara provides trainings about insurance, progress notes, and the business side of private practice. For answers to your questions about Medicare and insurance, check out her book and online courses.

Susan Frager MSW started as a clinician, worked for a managed care company, and for over 30 years honed her expertise as a biller.  Susan is an expert in Medicare billing and walks therapists through the complex enrollment process.  Check out her courses or schedule your consultation here.

 

Gia Reyes LMFT has a private practice in San Carlos, California, and serves on the Board of Directors for the Santa Clara Valley Chapter of the California Association of Marriage and Family Therapists, in charge of the newsletter.  Visit her website here.