Page 35 - Medicare Benefit Policy Manual

otherwise be covered by Medicare, or enters into private contracts that fail to meet
the specifications of §40.8; or

• The physician/practitioner fails to comply with the provisions of §40.28 regarding
billing for emergency care services or urgent care services; or

• The physician/practitioner fails to retain a copy of each private contract that the
physician/practitioner has entered into for the duration of the current 2-year
period for which the contracts are applicable or fails to permit CMS to inspect
them upon request.

B. Violation discovered by the Medicare contractor during the current 2-year
period.

If a physician/practitioner fails to maintain opt-out in accordance with the provisions
outlined in paragraph (A) of this section, and fails to demonstrate within 45 days of a
notice from the Medicare contractor that the physician/practitioner has taken good faith
efforts to maintain opt-out (including by refunding amounts in excess of the charge limits
to the beneficiaries with whom the physician/practitioner did not sign a private contract),
the following will result effective 46 days after the date of the notice for the remainder
of the opt-out period:

1. All of the private contracts between the physician/practitioner and Medicare
beneficiaries are deemed null and void.

2. The physician’s or practitioner’s opt-out of Medicare is nullified.

3. The physician or practitioner must submit claims to Medicare for all Medicare
covered items and services furnished to Medicare beneficiaries.

4. The physician or practitioner or beneficiary will not receive Medicare payment on
Medicare claims for the remainder of the opt-out period, except as stated above.

5. The physician or practitioner is subject to the limiting charge provisions as stated
in §40.10.

6. The practitioner may not reassign any claim except as provided in Pub. 100-04,
Medicare Claims Processing Manual, Chapter 1, “General Billing Requirements,”
§30.2.13.

7. The practitioner may neither bill nor collect any amount from the beneficiary
except for applicable deductible and coinsurance amounts.

8. The physician or practitioner may not attempt to once more meet the criteria for
properly opting out until the current 2-year period expires.