Page 41 - Medicare Benefit Policy Manual

Physicians and practitioners cannot have private contracts that apply to some covered
services they furnish but not to others. For example, if a physician or practitioner
provides laboratory tests or durable medical equipment incident to his or her professional
services and chooses to opt-out of Medicare, then the physician/practitioner has opted out
of Medicare for payment of lab services and Durable Medical Equipment, Prosthetics,
and Orthotics (DMEPOS) as well as for professional services. If a physician or
practitioner has a valid opt-out affidavit on file with the MAC, has a valid NPI, is a
specialty that is eligible to order or certify, and refers a beneficiary to a non-opt-out
physician or practitioner for medically necessary services, such as laboratory, DMEPOS
or inpatient hospitalization, Medicare would cover those services.

In addition, because suppliers of DMEPOS, independent diagnostic testing facilities,
clinical laboratories, etc., cannot opt-out, the physician or practitioner owner of such
suppliers cannot opt-out as such a supplier. Therefore, the participating physician or
practitioner becomes a nonparticipating physician or practitioner for purposes of
Medicare payment for emergency and urgent care services on the effective date of the
opt-out. (See §40.28).

40.19 - Opt-Out Relationship to Noncovered Services
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)

Because Medicare’s rules do not apply to items or services that are categorically not
covered by Medicare, a private contract is not needed to furnish such items or services to
Medicare beneficiaries, and Medicare’s claims filing rules and limits on charges do not
apply to such items or services. For example, because Medicare does not cover hearing
aids, a physician or practitioner, or other supplier may furnish a hearing aid to a Medicare
beneficiary and would not be required to file a claim with Medicare; further, the
physician, practitioner, or other supplier would not be subject to any Medicare limit on
the amount they could collect for the hearing aid.

If the item or service is one that is not categorically excluded from coverage by Medicare,
but may be noncovered in a given case (for example, it is covered only where certain
clinical criteria are met and there is a question as to whether the criteria are met), a non-
opt-out physician/practitioner or other supplier is not relieved of his or her obligation to
file a claim with Medicare. If the physician or practitioner or other supplier has given a
proper Advance Beneficiary Notice (ABN), he or she may collect from the beneficiary
the full charge if Medicare does deny the claim.

Where a physician or practitioner has opted out of Medicare, he or she must provide
covered services only through private contracts that meet the criteria specified in §40.8
(including items and services that are not categorically excluded from coverage but may
be excluded in a given case). An opt-out physician or practitioner is prohibited from
submitting claims to Medicare (except for emergency or urgent care services furnished to
a beneficiary with whom the physician or practitioner did not have a private contract).
(See §40.12.)