Medicare opt-out

Opting out is a decision to leave Medicare billing entirely, not a way to skip it for some patients. Section 1802 of the Social Security Act lets a physician or practitioner opt out and enter into private contracts with Medicare beneficiaries. While the opt-out lasts, Medicare covers nothing that clinician furnishes and pays neither the clinician nor the patient for it, and the choice cannot be made for some beneficiaries or some services only¹.

For opt-out purposes the manual counts doctors of medicine, osteopathy, dental surgery or dental medicine, podiatric medicine and optometry as physicians, and lists practitioners such as physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, clinical psychologists, clinical social workers and registered dietitians. Chiropractors cannot opt out, and neither can physical or occupational therapists in independent practice¹. Affidavits signed on or after June 16, 2015 renew automatically every 2 years. To stop a renewal, the clinician notifies each MAC in writing at least 30 days before the next period begins¹.

Two exceptions reach the billing office. In an emergency or urgent care situation, an opted-out clinician may treat a beneficiary who has no private contract, must submit that claim to Medicare for the patient, and may not charge more than a nonparticipating clinician could¹. Medicare also still pays for covered services an opted-out clinician orders or certifies, such as a hospital stay after an admission, when the clinician has an NPI, reports a Social Security Number, has a valid affidavit on file with the MAC and belongs to a specialty eligible to order and certify¹. A clinician who has never opted out before can end the opt-out only within 90 days of the affidavit’s effective date¹.