Page 34 - Medicare Benefit Policy Manual

B. If a physician/practitioner fails to properly opt-out in accordance with the above
paragraphs of this section, the following will result:

• The physician’s or practitioner’s attempt to opt-out of Medicare is nullified, and
all of the private contracts between the physician/practitioner and Medicare
beneficiaries for the 2 year period covered by the attempted opt-out are deemed
null and void;

• The physician/practitioner must submit claims to Medicare for all Medicare-
covered items and services furnished to Medicare beneficiaries, including the
items and services furnished under the nullified contracts. A nonparticipating
physician/practitioner is subject to the limiting charge provision. For items or
services paid under the physician fee schedule, the limiting charge is 115 percent
of the approved amount for nonparticipating physicians or practitioners. A
participating physician/practitioner is subject to the limitations on charges of the
participation agreement the physician/practitioner signed;

• The physician/practitioner may not reassign any claim except as provided in the
Medicare Claims Processing Manual, Chapter 1, “General Billing
Requirements,” §§30.2.12 and 30.2.13;

• The physician/practitioner may neither bill nor collect an amount from the
beneficiary except for applicable deductible and coinsurance amounts; and

• The physician/practitioner may make another attempt to properly opt-out at any
time.

40.11 - Failure to Maintain Opt-Out
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)

A. Failure to maintain opt-out

A physician/practitioner fails to maintain opt-out under this section if during the opt-out
period one of the following occurs:

• The physician/practitioner has filed an affidavit in accordance with §40.9 and has
signed private contracts in accordance with §40.8, but the physician/practitioner
knowingly and willfully submits a claim for Medicare payment (except as
provided in §40.28) or the physician/practitioner receives Medicare payment
directly or indirectly for Medicare-covered services furnished to a Medicare
beneficiary (except as provided in §40.28); or

• The physician/practitioner fails to enter into private contracts with Medicare
beneficiaries for the purpose of furnishing items and services that would