Your options with regard to Medicare

August 10, 2011

The author discusses participating versus nonparticipating status with Medicare and opting out.

Q: I have seen conflicting information concerning opting out and participating versus nonparticipating status with Medicare. One article I recently read gave an example of a physician who did not accept any insurance, including Medicare. He worked in a resort area where he made house calls and accepted only cash payments for his services, yet he was part of a group practice that was participating with Medicare. Other articles I have read seem to indicate that a doctor cannot be both nonparticipating and participating. What is the real answer?

If a physician "opts out" of Medicare, however, the situation is different. By opting out, the doctor no longer is recognized as a provider in the program and, therefore, cannot receive any compensation from Medicare, either directly or indirectly. For instance, one physician in a group can't opt out while the rest of the group members remain either participating or nonparticipating.

In the scenario you describe (the resort physician), if the doctor was credentialed as nonparticipating in his own individual practice for his resort-area work and only charged patients the limiting charge, then the article you read would be correct, as long as the physician didn't violate any other provider contracts his other group had executed with other insurers and the doctor submitted claims to Medicare for the services he provided to Medicare beneficiaries through his nonparticipating practice.

The author is president of Healthcare Consulting Associates of NW Ohio Inc., Waterville, and a Medical Economics editorial consultant. She has more than 30 years of experience as a practice management consultant and also is a certified coding specialist, certified compliance officer, and certified medical assistant.

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