Page 25 - Medicare Benefit Policy Manual

mandatory claim submission rules of §1848(g)(4) of the Social Security Act when
a claim is not submitted per a beneficiary’s written request on an ABN. Where a
valid ABN is given and a claim is submitted, subsequent denial of the claim
relieves the non-opt-out physician/practitioner, or other supplier, of the limitations
on charges that would apply if the services were covered.

Opt-out physicians and practitioners must not use ABNs, because they use private
contracts for any item or service that is, or may be, covered by Medicare (except for
emergency or urgent care services (see §40.28)).

Where a physician/practitioner, or other supplier, fails to submit a claim to Medicare on
behalf of a beneficiary for a covered Part B service within 1 year of providing the service,
or knowingly and willfully charges a beneficiary more than the applicable charge limits
on a repeated basis, he/she/it may be subject to civil monetary penalties under
§§1848(g)(1) and/or 1848(g)(3) of the Act. Congress enacted these requirements for the
protection of all Part B beneficiaries. Application of these requirements cannot be
negotiated between a physician/practitioner or other supplier and the beneficiary except
where a physician/practitioner is eligible to opt out of Medicare under §40.4 and the
remaining requirements of §§40.1 - 40.38 are met. Agreements with Medicare
beneficiaries that are not authorized as described in these manual sections and that
purport to waive the claims filing or charge limitations requirements, or other Medicare
requirements, have no legal force and effect. For example, an agreement between a
physician/practitioner, or other supplier and a beneficiary to exclude services from
Medicare coverage, or to excuse mandatory assignment requirements applicable to
certain practitioners, is ineffective.

The A/B MAC (B) will refer such cases to the OIG.

This subsection does not apply to noncovered charges.

40.1 - Private Contracts Between Beneficiaries and
Physicians/Practitioners

(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)

Section 1802 of the Act, as amended by §4507 of the BBA of 1997 and §106 of the
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10),
permits a physician/practitioner to opt-out of Medicare and enter into private contracts
with Medicare beneficiaries if specific requirements of this instruction are met.

40.2 - General Rules of Private Contracts
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)

The following rules apply to physicians/practitioners who opt-out of Medicare: