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Billing Medicare when out of network

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Linda, for the sake of those who may not know, can you be a bit more specific on what you meant with your post.

We just went through this with a couple of our clients.  There are two states of being here:

Non-Participating Physician (with its attendant pay calculations) - must still file an insurance claim with Medicare.

Physicians who totally opt out of Medicare (good for two years at a time) - cannot file insurance claims with Medicare but must have a Private Contract with each Medicare patient who choses to see them.

It is a bit more complicated than simply treating Medicare folks as cash patients.

Part of the point of CMS is to protect Medicare folks from being treated as cash patients - where the patient can be charged whatever the doctor wants to charge, as allowed by his State regulations.  Bottom line, doctors can't ever really walk away from the Medicare regulations.  They have to follow them if the see Medicare folks, even if the doctor has opted out of Medicare - which they can only do for two years at a time (opt-out can then be renewed for another two-year stint).

Your points are valid Richard but this is more than par or non par or opting out. This specialty is not covered by Medicare. So l agree with Linda. Would be the same as billing massage therapy to Medicare.

So we should change the subject line. This has nothing to do with a network. It is about a non covered specialty unlike an uncovered procedure.

Merry - I was requesting clarification from Linda about this statement:

non Medicare clients ... [re.] Medicare Patients ... they are treated as cash patients.

I guess the key phrase here is "non-covered service".

From the link I provided above, re. the opt-out provider and private contracts:

Enter into a private contract for, and prior to, rendering any covered services ...

Key phrase in requirement for private contract is "covered services".  I missed that.  So it would seem that those Medicare patients seeking a non-covered service can indeed be treated as a cash patient.

Thanks for helping me clarify this to myself.

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>


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