Medicare Clients: Can You See Them if You Aren’t a Medicare Provider?
By Barbara Griswold, LMFT (updated March 9, 2023)
If you are a provider who is currently eligible to participate in Medicare (ex. psychologists and social workers), but you choose not to, you must formally “opt-out” of Medicare if you want to see a Medicare client in your practice and accept direct payments from the client. Unlike other private health plans, where you can just choose not to join as a provider, with Medicare you have to file an opt-out affadavit in writing stating that you do not want to participate. If you don’t, Medicare could force you to refund any money paid to you by a Medicare client until you formally opt out. Opt-outs can’t be retroactive, so do it now!
After formally opting out (following the steps below), Remember: you will need to download Medicare’s private contract for use with private pay clients.
The steps to opting-out, for eligible Medicare providers (ineligible providers skip this section):
1. If you don’t know, determine who administers the Medicare contract in your area, also known as the Medicare Administrative Contractor (MAC). Click here for a list
2. Once you see who administers the Medicare contract in your area, go to their website — the Provider Opt-Out Affidavit is almost always under the Part B main page — look for the link or topic “Provider Enrollment” – or there could be its own category “Opt Out.” If you can’t find it, go to your search engine and type in the name of the administrator followed by the words “Provider Opt-Out” (ex. “Noridian Provider Opt-out”). Be sure you don’t click on a website regarding a client opting out of Medicare.
If you want to see the client, you will then need to set up a private contract with the client. Some MACs have a sample private contract on their site – some don’t. It is recommended that you use one of the downloadable ones, even if it’s from a different Medicare contractor. It must go on your letterhead. “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 client, and require you to file claims for the rest of that opt-out period,” says Susan Frager, a certified biller and owner of Your Billing Buddy (www.yourbillingbuddy.com). “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. All it takes for Medicare to audit whether you adhered to the rules of opt-out is if you or your client to file a claim or superbill.“
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.
Susan’s blog has a little more about it: click here
Susan is a great resource for Medicare questions. You can contact her at firstname.lastname@example.org.