Monday, September 20, 2010

Will My Opt-Out Status Affect You?

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I opted out of Medicare several years ago.  This means I don’t see Medicare patients other than in the emergency room when I’m on unassigned call.   I don’t submit bills to Medicare or to those patients.  I just let it slide.
Last Wednesday, I received the following letter from a large radiology group in my home town:
September 2010
RE:  PECOS Enrollment
To our referring physicians and their office managers:
At __________we have begun a project to identify ordering physicians who are not enrolled in Medicare’s Provider Enrollment, Chain and Ownership System (PECOS).  Our purpose is to remind physicians of the importance of enrollment to them and to us.
Beginning in January, 2011 those providers filing Medicare claims listing an NPI number on the claim of an unenrolled provider will have their claims denied.  This would apply to any claim you send in and to any claim we submit for services provided to your patients because we are required to list your NPI number on our claims.  This applies both to patients referred to our private offices and the hospitals where we provide radiology professional interpretations or services.
So, you can see our effort is not purely altruistic.  We have a financial interest in reminding you of the importance of PECOS enrollment.  In trying to ascertain whether you are enrolled, we are using an online program you can find at  Simply enter your NPI number in the entry block and press enter.  If you enter a valid NPI number, your name will appear and beside it will be a symbol indicating where Medicare recognizes your PECOS enrollment.
Since Medicare is continually updating the files, we may have accessed the system before your enrollment was completed.  We will continue to monitor the situation in hopes you will enroll if you intend to continue seeing Medicare patients.  If you have already enrolled or have no plans to enroll, please excuse our intrusion.

This bothers me.  It is not likely that I will be sending them any patients from my office, but that doesn’t mean there won’t be the occasional patient with my name on their chart in the ER.  IF I need to take a Medicare patient to the operating room from the ER, will the hospital not get paid?  Will the anesthesiologist not get paid?
Will my non-participation in Medicare affect my fellow healthcare providers receiving payment?  If so, that is just not right.  I voiced this concern to Senator Blanche Lincoln shortly after receiving this letter.  She agrees with me.
This radiology group is usually correct in their policy interpretations, but I still went searching for more information.  I found this summary:  What You Need to Know about Enrolling and Ordering/Referring in the Medicare Program.  It includes this
Physicians who have validly opted out of Medicare will not need to complete a Medicare enrollment application.
Still, I am not reassured.   The policy doesn’t seem to take into account that I may through unassigned ER call see the occasional Medicare patient.  The policy seems to “assume” that since I opted-out, I never see any Medicare patients.  If this were the case, I would never affect my fellow physicians/hospitals payment.  I’m left wondering if I will affect their payments for that occasional patient I see through the unassigned ER route.
I will tell you that I have gone to the NPI site and reviewed my information.  I have gone to the Medicare (PECOS) site and attempted to registered my information.  I will not be re-enrolling as a Medicare provider at this point in time.  


Anonymous said...

I didn't know an MD COULD opt out from Medicare. Will that still be true under the new health reform law?

Would you please explain why you did this?

StorytellERdoc said...

Very interesting, Ramona. Your alertness to these politics impresses me...

Chrysalis said...

It sure seems like what you fear, is what the result will be. It has the feel of strong arming, doesn't it?

rlbates said...

Paul, I opted out because I was losing money for each Medicare patient I saw. I suppose I could have just limited the number of Medicare patients I saw so the remaining patients made up the them. To me this is wrong. The other patients shouldn't be paying for their own care and someone else.

rlbates said...

Paul, I don't have the answer for you on the second part (will doctors still be able to opt out under the new health reform law).

Dr. Jim, don't be impressed. My colleagues the radiologists alerted me to this.

CA, yes, to me it does have the feel of being "strong armed."

agent99 said...

A troubling policy change if true. My experience (and I treat better that 80% Medicare in my line of work) was that a provider can be non-participating in Medicare, meaning they did not accept assignment. Patients has to file their own claims and pay the Non-PAR rate out of pocket to the doctor. SO while a doc can opt-out of Medicare participation, I don't think a doc can refuse Medicare. They are simply now required to accept assignment.....As to refusing coverage of necessary studies for patients of Non-PAR docs - that seems to ridiculous to be true.... Please let us know how this works out.

rlbates said...

Agent99, I would have to reapply to Medicare to even be listed as a non-participating physician. It is true I can not refuse to see a Medicare patient ER patient when I'm on call, but I do not have to see them otherwise. IF I do, never the patient nor I can file. The patient has to literally agree to pay for their care out of pocket. That is the difference between opting out and non-participation.

The payment as a non-participating Medicare provider is not much, if any, better than participating MDs. The headaches certainly aren't any less.

Anonymous said...

Most hospitals require docs to be Medicare enrolled as a prerequisite for being on staff. If this is not the case for you, expect some by-law changes real soon.