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Billing Medicare when out of network

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RichardP:
OK.  That response just confused me again.

It is my understanding that a doctor can see a Medicare patient only if s/he complies with one of three conditions - each of which has their own requirements.

1.  Participating Provider
2.  Non-Participating Provider
3.  Opted-Out

Are you aware of any conditions other than these three under which a doctor may see a Medicare patient and expect to get paid by someone?

It is my understanding that, if a doctor wishes to see a Medicare patient for a covered service, and he is not either PPO or non-PPO with Medicare, he must be in the opted-out category.  And this category requires that the doctor have a private contract with each patient for all covered services he performs.  Every. Time. He. Performs. Them.

It is my understanding that, for an opted-out doctor performing a covered service, it can never be cash-only at the time of service.  There must be a private contract established before the service can be performed, per the link I provided above.

What am I missing?

This is not an idle question.  We have a number of clients who would opt out, except for the private contract requirement (that requirement gets burdensom when they see many Medicare patients per day).  If that private contract requirement does not actually exist, it becomes a new ballgame.  Except that I have not found any documentation that says opted-out docs can see Medicare patients for covered services without that private contract being establish first.

PMRNC:
I don't know what your missing.. again:

NO MEDICARE ACCEPTED for client(s) I was speaking of. I have one Masters level who NEVER got into Medicare and all rest of my clients with the exception of 1 OPTED out.  CASH Only at time of service. Yes it is that simple <g>

there is NO MEDICARE PERIOD. Those providers have notified and adhered to Medicare opt out for the one that opted out.. for the other who was NEVER in Medicare, no further explanation is needed. CASH pay. I'm not sure what you are missing, but we are not missing anything.

RichardP:
Linda - my question is a serious one, and your response doesn't seem to be serious.  I listed three options for doctors regarding Medicare, and none of them grant the freedom that you are claiming.  So my question, seriously, is there a fourth option that I am missing?

It seems that you are defining a fourth category of doctor - those who were never part of Medicare to start with.  Serious question, so serious answer please.  Can a doctor get his license to practice medicine and never deal with Medicare from the get-go?  (I thought every doctor had to place themselves into one of the 3 categories I listed above.)  If so - that would be a fourth category that I was not aware existed.  But that is not the case with any of our clients.  None of our clients has never had any dealings with Medicare.  I imagine that is the rule for most medium to small billers.

A while back you commented that all of your clients were now Medicare-free.  If you stated somewhere that some of them were Medicare-free because they had never ever had any dealings with Medicare, I missed that.  It appeared to me that you had opted all of them out.

Those providers have notified and adhered to Medicare opt out for the one that opted out ...

I presume this one is renewing his opt-out status every two years, and is creating private contracts for all Medicare patients who are receiveing covered services?  If yes, that is not an experience as simple as a cash patient.  And if no, I would hope s/he doesn't get turned in.

PMRNC:
Richard, I think your making too much out of nothing.

The one provider I have has NEVER had a thing to do with Medicare.. period.. what she does, what she charges.. is MOOT. She has that right.

The other one I'm speaking of (dealing with mental health) OPTED OUT OF MEDICARE.. did the whole legal mumbo jumbo to opt out. So what she charges.. is also MOOT. She has notified patients legally as per the opt out and her affidavit sent in.

I don't KNOW what you are reading..but those providers who have NEVER taken Medicare or opted OUT of Medicare have nothing to do with Medicare.. Period. It really IS THAT SIMPLE!!   My providers with the exception of ONE.. have opted out of all govt payors. They are now NO longer controlled at ALL by govt payor rules. PERIOD.    I have ONE client taking medicaid but ONLY until 4/1 and then I will be completely OUT of billing all govt payors.

DMK:
You have to register with Medicare for them to even know you exist.  If you never register, Medicare doesn't know who you are and you can not bill them, even for a denial.  You don't exist to them.  It IS a doctor's choice to take insurance (any insurance) or not.  You can charge cash pay to anyone you want.  Where you run into the issues is when you HAVE signed up with insurance or Medicare and then you try to negotiate a price with the client. You don't get to do that without jumping through a bunch of hoops.

If the provider provides a service not covered by Medicare, what would be the point in signing up or opting out?  It's not necessary, just charge a cash fee schedule.

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