Orders Paid for by Medicare when Ordered by Opted Out Providers?

(Lissa Lubinski) #1

Just a quick question to clarify: When we opt out of Medicare, our orders are still acknowledged and billable to Medicare, correct? If I order an MRI and it’s justified by my note and have appropriate ICD10, then Medicare would acknowledge and presumably pay for the MRI, right? They wouldn’t decline to pay for the MRI simply because an opted out MD ordered it. Same with referrals, labs, etc. That was my understanding. But this makes a huge impact on moving forward with this.

Re: Medicaid, I don’t know if it changes state to state and if this is better addressed with legal support, but does Medicaid allow (in WA) MDs to order and refer for Medicaid patients if you’re not billing Medicaid?

Thank you!

(Appalenia Udell, Esq.) #2

Hi @lklubinski,
In WA, referring and ordering status requires enrollment as a participating provider; you can view the FAQ. For Medicare, yes, as of November 2016, CMS still allows R&O status to opted out docs provided they remain “enrolled” and use their NPI for the order see the MLN here.

(Lissa Lubinski) #3

Thank you so much!

(Siobhan Benham) #4

I have another question regarding opting out of Medicare- if you opt out you use your NPI as an identification right? What if you also moonlight at an urgent care that bills insurance, will that carry over to the other job?

(Appalenia Udell, Esq.) #5

Dear @SBNP,
Medicare opt-out is specific to the provider NPI. If a provider opts-out, and then works part-time in a facility that bills non-emergency services, then that provider’s services will be denied reimbursement. There is a very narrow exception for emergency services, but many employers are unwilling to underwrite the risk of non-reimbursement.

When considering opting-out of Medicare, we encourage a robust examination of the implications (both positive and negative) over time, as opting-out can mean the inability to secure a job for up to 2 years. For primary income earners, this is often reason enough to stay opted-in and simply not see Medicare patients in a DPC setting.

DPCs with a commitment to Medicare populations will often develop hybrids so they can continue to care for this group of patients while maintaining their DPC practice for non-Medicare patients. There is a similar model for Medicaid recipients, though the financial projections have to be carefully monitored for continued viability.

Hope this is helpful!

(Siobhan Benham) #6

Thank you so much. This was helpful.