1): My question is about waiver of beneficiary coinsurance and deductibles. Can a physician give a discount to a family member or close friend by not billing Medicare?
Medicare does not pay for services provided to any beneficiary related to the provider because these services would normally be provided free of charge. A detailed article can be found on Page 17 of the April 1997 Medicare Advisory. A provider should not bill Medicare for these services because he/she is normally providing these services free of charge. If providers choose to not bill Medicare and charge the beneficiary his normal charge, he/she would have to opt out of the Medicare program and establish a private contract with that patient.
2. Can physicians or practitioners who are suppliers of durable medical equipment (DMEPOS), independent diagnostic testing facilities, clinical laboratories, etc., opt out of Medicare for only these services?
No. If a physician or practitioner chooses to opt out of Medicare, it means that he or she opts out for all covered items and services he or she furnishes. Physicians and practitioners cannot have private contracts that apply to some covered services they furnish but not to others.
3. What happens if a physician or practitioner who opts out is a member of a group practice or otherwise reassigns his or her Medicare benefits to an organization?
Where a physician or practitioner opts out and is a member of a group practice or otherwise reassigns his or her rights to Medicare payment to an organization, the organization may no longer bill Medicare or be paid by Medicare for the services that physician or practitioner furnishes to Medicare beneficiaries.
However, if the physician or practitioner continues to grant the organization with the right to bill and be paid for the services he or she furnishes to patients, the organization may bill and be paid by the beneficiary for the services that are provided under the private contract.
The decision of a physician or practitioner to opt out of Medicare does not affect the ability of the group practice or organization to bill Medicare for the services of physicians and practitioners who have not opted out of Medicare.
4. Can organizations that furnish physician or practitioner services opt out?
No. Corporations, partnerships, or other organizations that bill and are paid by Medicare for the services of physicians or practitioners who are employees, partners, or have other arrangements that meet the Medicare reassignment-of-payment rules cannot opt out since they are neither physicians nor practitioners.
5. Where and when must the opt-out affidavit be filed?
An opt-out affidavit must be filed with each carrier that has jurisdiction over the claims that the physician or practitioner would otherwise file with Medicare and must be filed within 10 days after the first private contract to which the affidavit applies is entered into.
6. How often can a physician or practitioner opt out or return to Medicare?
Pursuant to the statute, once a physician or practitioner files an affidavit notifying the Medicare carrier that he or she has opted out of Medicare, he or she is out of Medicare for 2 years from the date the affidavit is signed. After those 2 years are over, a physician or practitioner could elect to return to Medicare or to opt out again.
7. Will Medicare make payment for services that are ordered by a physician or practitioner who has opted out of Medicare?
Yes, provided the opt-out physician or practitioner ordering the service has acquired a uniform provider identification number (UPIN) and the services are not furnished by a physician or practitioner who has also opted out.
8. Clinical psychologists and clinical social workers are currently not recognized by and enrolled by Medicare unless they meet certain criteria specified by HCFA, some of which are voluntary. Are the requirements for opting out of Medicare different for these practitioners?
No. A clinical psychologist or clinical social worker must meet the affidavit and private contracting rules to opt out of Medicare.
9. How do the private contracting rules work when Medicare is the secondary payer?
Under this circumstance, no Medicare secondary payments will be made for items and services furnished by the physician or practitioner under the private contra
