aapp-medicareMedicare coverage was specifically designed with two goals in mind: to help those whose ability to afford healthcare coverage has been affected by age or disability continue to receive quality medical care, and to provide a financial incentive to physicians to provide such care. Coincidentally, it’s those within the Medicare patient population who require a majority of the health care services in America. Yet in some instances, the guidelines that physicians must follow in order to remain compliant with Medicare standards can actually hinder their ability to provide care.

Why Providers Opt Out

In many instances, it’s not a desire to not have to jump through proverbial hoops that drives the desire to end one’s Medicare participation. Rather, it’s the restrictions placed on the ability to provide certain levels of care that frustrate physicians to the point of wanting to end their federal associations. In other cases, the limitations on reimbursement may make it difficult for independent doctors and private practices to reclaim the money needed in order to provide the highest level of care for their patients. In the competitive world that health care is quickly becoming, an inability to provide patients with the most advanced treatment available due to restrictive federal reimbursement guidelines can quickly spell doom for any private practice.

Yet opting out puts an even greater burden on physicians to communicate effectively with their patients. While the goal of opting out is typically to help a physician improve overall patient care, it requires that patient’s assume a much greater responsibility in managing their own treatment. The guidelines put in place by Medicare are meant to both limit the procedures that a doctor can perform to those only deemed to be medically necessary, and to limit providers from overcharging patients for their services. Thus, those patients whose doctors have opted out need to have a very clearly-defined standard in place when it comes to their treatment.

Clearly Establishing Patient Responsibilities

In accordance with Amendment 4507 of the Balanced Budget Act of 1997, doctors who’ve opted out are required to have private contracts in place with those Medicare beneficiaries who retain their services. It’s these contracts that set the aforementioned standard in defining the responsibilities of both sides involved in the execution of treatment plan. As patients assume the full role of guarantor in these scenarios, it’s vital that they understand their responsibilities as set forth in these contracts.

As part of his or her decision to enter into a private contract with an opted out physician, a patient must be made to understand the following obligations:

  • That the provider is excluded from Medicare
  • That he or she agrees to not submit any claims to Medicare for services rendered
  • That procedures otherwise payable by Medicare will not be covered when performed by this particular provider
  • That he or she accepts full responsibility for the repayment of any services received
  • That the provider is not bound by regulatory practice and billing limits set forth by Medicare
  • That he or she is entitled to seek such services from another Medicare-participating provider
  • That Medigap or other supplemental coverage may not be extended to services not paid for by Medicare

Physicians can help their patients in fully understanding the responsibilities that they assume under such an agreement. Through clear and concise communication, it can easily be conveyed that the one’s decision to not participate with Medicare has everything to do with providing a higher overall level of care.

Opting out of Medicare participation presents a whole new world of challenges for both physicians and their patients to have to deal with. Yet in many instances, the net benefit of making such a decision makes dealing with those challenges worth it for both sides. Doctors who’ve chosen to plot their own course outside of the Medicare umbrella aren’t without assistance, either. At AAPP, we provide support to private practices that are looking to make high-level medical care more accessible to their patients. We offer doctors the chance to collaborate on shared issues in order to further their own practices as well as to provide guidance to others. Our goal is nothing less than to drive the evolution of health care.