Origonal Medicare, Opt Out Status, Medicare Enforcement

G

Gene

New Member
My Doctor of 7 years said we will no longer accept Original Medicare as none of the 30 doctors in the practice will as of january 1. My doctor was opposed to the decision. In reading on this, I find three classifications for a medicare network provider. 1, Participating. 2. Non-participating. 3. Opt out for 2 years. I know they are not longer participating under 1 because they will not bill original medicare any longer. I know they are not a non-participating because they said they will not accept the 15% up charge for anyone in Original Medicare. It would appear, because they are so adamant that they will never bill original medicare again for anyone that they opted out. That said, when you opt out you must file the opt out affidavit with Medicare and Medicare.gov sites which show who has opted out do not show them as ever filed any affidavit or ever opted out. Checking with 1-800-Medicare they stated there lists are up to date and to my surprise all doctors in that network practice are on record of still accepting original medicare patients. But the practice says they will continue to take 6 different Medicare advantage plans. So the new status of opting out doing nothing concerns me. So I look for guidance on this OPT OUT and I find the nordian MAC contractor site. https://med.noridianmedicare.com/web/jeb/enrollment/opt-out

It states the Following:\
If you opt out, beware of the following:

  • An Affidavit must be filed with all carriers who have jurisdiction over claims the physician/practitioner would otherwise file with Medicare.
  • The opt out period last two years.
  • All active Medicare enrollments will be terminated.
  • Opting out means you cannot be involved in any Medicare program; including original fee-for-service Medicare, Medicare Managed Care Plans, Medicare+Choice Plan and Medicare Advantage Plan.
  • Providers cannot be opt out for some services and not others, as well as some locations and not others.
  • No payment through Medicare with the exception of Emergency or Urgent Care services.
So now I am puzzled because they do not fit under any classification. My thought is they have to file an opt out affidavit to no longer accept Original medicare patients in which they fired over 1000 original medicare patients. But if they opt out, they can no longer have the 6 advantage plans either. While the Nordian Mac contractor lists these rules, no one at Medicare knows anything about opting out, non-par, or par physician contracts. Any ideas of what is going on here, is Medicare misreporting when they say they are in network for original medicare.
 
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Very few providers go through the formal "opt out" process you describe. They most likely remain either a participating provider or non-participating provider as indicated on the Medicare website and chosen to no longer treat original Medicare enrollees.

A participating provider has the option of treating or not treating original Medicare beneficiaries in non-emergency situations. There is no provider network with original Medicare. Only when the participating provider decides to see an original Medicare beneficiary do the rules for participating providers kick in. Once the participating provider decides to see the beneficiary, they must submit the claim to original Medicare and not balance bill. The provider can also choose to see original Medicare beneficiaries at one practice location and not another.

A non-participating provider has the option of treating or not treating original Medicare beneficiaries in non-emergency situations. Only when the non-participating provider decides to see an original Medicare beneficiary do the rules for non-participating providers kick in. Once the participating provider decides to see the beneficiary, they must submit the claim to original Medicare. The non-participating provider can balance bill within certain limits if they do not accept assignment on the claim.
 
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Thank you for the response. They are listed every where as a Medicare provider for original medicare and do accept assignment. If I understand you correctly, they can choose, as they have done, to let all current beneficiaries go and not accept anyone again. That most likely they will remain in the status of a participating provider who never opted out. Because they are participating, they can choose to accept to accept any medicare beneficiary on the basis of original medicare or advantage plans. The other issue here is I told them That I also have medical insurance from the employer I retired from. It is not a supplement but rather a full medical policy the same as active employees currently receive. It is a United Healthcare commercial policy for which they are in network with. They stated to me, that even though they are under contract with United Healthcare and they do take my United healthcare plan, that for those who have Original Medicare, they will not accept any other insurance they may have. This is some thing I have never heard of. They also are not a provider for Aetna, so if someone comes in with Aetna, they can say they will not accept a United Healthcare policy because the person has Aetna. I am wondering how all this will pay out with coordination of benefits.
 
Gene said:
Thank you for the response. They are listed every where as a Medicare provider for original medicare and do accept assignment. If I understand you correctly, they can choose, as they have done, to let all current beneficiaries go and not accept anyone again. That most likely they will remain in the status of a participating provider who never opted out. Because they are participating, they can choose to accept to accept any medicare beneficiary on the basis of original medicare or advantage plans. The other issue here is I told them That I also have medical insurance from the employer I retired from. It is not a supplement but rather a full medical policy the same as active employees currently receive. It is a United Healthcare commercial policy for which they are in network with. They stated to me, that even though they are under contract with United Healthcare and they do take my United healthcare plan, that for those who have Original Medicare, they will not accept any other insurance they may have. This is some thing I have never heard of. They also are not a provider for Aetna, so if someone comes in with Aetna, they can say they will not accept a United Healthcare policy because the person has Aetna. I am wondering how all this will pay out with coordination of benefits.
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If it is a retirement program it is actually secondary to medicare. Medicare is only secondary while you are working.
 
Correct, it is secondary. The doctors group will not submit claims to the primary even though they are a network provider. Both Medicare and United tell me that if the primary does not want to submit claims, that I can submit to medicare myself and then United says they will accept the EOB from medicare and pay what they owe. My surprise is that Medicare holds this medical group out as a group who will accept original medicare when they do not. I would have thought there would have been a contract a doctors group would have signed with medicare stating that if they are listed, that they would take medicare beneficiaries under that contract. If you call medicare, Medicare will say yes, they will see you there if you have original medicare.
 
Medicare takes a long time to update their system. I would take what the Dr's are telling you.
 
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