Massachusetts Speech-Language Hearing Association

No "opt out" option for Medicare - what now?

01 Mar 2016 12:14 PM | Barbara Wilson Arboleda (Administrator)

Many of us in speech-language pathology and audiology recall the enthusiasm of 2009 when we finally achieved the ability to obtain provider status with Medicare. For some, this became a mixed blessing due to the fact that neither speech-language pathologists nor audiologists were given the ability to “opt out” of Medicare provider status. The ability to be a provider with Medicare became an obligation to be a provider with Medicare in order to provide treatment to Medicare beneficiaries.


The speech-language pathologist or audiologist who is not aware of this restriction can easily run afoul of the law in this regard and could end up in a boatload of trouble. The purpose of this post is to outline the basics of the opt out rule and how to navigate the restrictions presented by not being able to opt out of Medicare provider status.


Certain providers are allowed to “opt out” of being Medicare providers. These include physicians, physician assistants, nurse practitioners, clinical social workers and clinical psychologists among others. When a provider opts out of Medicare, they must send formal notice to CMS that they do not intend to participate. There is a contract that is signed between the provider and each Medicare beneficiary they treat stating that neither the provider nor the patient will submit a bill for the services to the Medicare program and the patient pays the provider for the services directly.


Neither speech-language pathologists nor audiologists are allowed to do this. So if you have been operating under the belief that you can opt out and sign a contract or an ABN with your patients for private treatment, you must stop. You are putting your professional livelihood at great risk if you continue.


So, what can you do if you don’t want to process Medicare claims yourself, but you want to treat the elderly population, most of whom are Medicare beneficiaries?


The first piece of information that is helpful to understand is the distinction between provider enrollment and the payment relationship of the provider to Medicare. When enrolling as a provider with Medicare, you have the option of enrolling as a “participating” or a “non-participating” provider. A participating provider treats the patient, bills Medicare directly and receives payment directly from Medicare as well. A non-participating provider is paid up front by the patient and the patient submits the charge to Medicare. As long as you are enrolled as a Medicare provider, you are allowed to see Medicare beneficiaries as a non-participating provider.


This sounds like the best of both worlds, right? Before you go celebrating too much, it is important to know that a non-participating provider is still restricted in terms of what they are allowed to bill for services. A non-participating provider is only allowed to charge up to 115% percent of the “allowable” charge for the service provided, if they do not accept “assignment” from Medicare (that is to have Medicare pay you directly) and if the providers “usual and customary charge” is at least that price. If the provider accepts Medicare assignment, the provider is only allowed to charge 95% of the allowable charge. The patient pays 20% of this and the rest is paid by Medicare. Both participating and non-participating providers must follow Medicare regulations regarding documentation and certification.


Each clinician will have to decide for themselves whether to be a participating or a non-participating provider. Fortunately, if you are a part of a group practice each provider can still choose to be participating or non-participating independently of the others in the practice. Every provider who treats Medicare patients must enroll as a Medicare provider, however, in order to be in compliance with Medicare regulations.


Special thanks to Kate Ogden, Health Policy Associate at ASHA, for her guidance and clarifications in preparing this post. 


CMS guidance for calculation of non-participating fees can be found here: 

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareClaimSubmissionGuidelines-ICN906764.pdf


Comments

  • 07 Mar 2016 2:58 PM | Briana O'Neill
    Barbara- Thank you for this informative post!
    Link  •  Reply
Massachusetts Speech-Language Hearing Association
465 Waverley Oaks Road, Suite 421, Waltham, MA 02452
Phone: 781-647-7031
theoffice@mshahearsay.org
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