Medicare Participation – Know your options

Physicians can review and modify their Medicare participation status through Dec. 31, 2012.

Whether or not you are thinking about modifying your Medicare status, PCMS encourage our members to prepare for this opportunity and review participation options carefully to determine the direction that is right for your practice. The PAMED has developed a list options  for considerations  to change their Medicare participation status. This decision is complex due to Medicare and Pennsylvania requirements.
Considering making a change, here are some of your choices:

  1. Become a non-participating provider
  2. Opt out of Medicare
  3. Close the practice to new Medicare patients

Become a non-participating provider
Pennsylvania’s Medicare Overcharge Measure, or MOM law, prevents non-participating physicians from charging patients more than the Medicare allowance. Non-participating physicians are paid 95 percent of the Medicare fee schedule for participating physicians and are also required to submit claims to Medicare on behalf of their Medicare patients. As a result, physicians who choose not to participate with Medicare will experience a 5 percent decrease in their Medicare revenue (in addition to the projected 26.5 percent cut) without a corresponding decrease in their overhead.

Opt out of Medicare
Opting out of Medicare removes the physician from Medicare entirely. Except for emergency or urgent-care situations, the physician may not bill Medicare nor can the beneficiary receive any payment from Medicare for the physician’s services. A physician who opts out must do so for all Medicare beneficiaries. Physicians who opt out may not re-enroll in Medicare for two years.

Physicians who have opted out and their Medicare patients may enter into private contracts through which the patient agrees to give up Medicare’s payment for the physician’s services and to pay the physician his established fees. Medicare does not impose any limits on what the physician may charge.

Physicians who choose to opt out of Medicare will need to give their patients ample notice to avoid any possible lapse in their care. Thirty days notice is the general recommendation. You should provide any emergency care that is necessary during the notification period. Read more about terminating the physician-patient relationship.

Close the practice to new Medicare patients
Whether or not a physician participates with Medicare, he has the right to close his practice to new Medicare patients. In the long term, this move will limit your direct exposure to further cuts in the Medicare fee schedule by eventually reducing the number of Medicare patients seen in your practice. Physicians may also want to consider the loss of the community’s goodwill.

The choice to distance your practice from Medicare, however, will not completely shield you from Medicare’s impact. Many commercial fee schedules are directly tied to the Medicare fee-for-service physician fee schedule.

Practices are wise to be prepared for the possibility of eventual cuts in commercial payments. In addition, physicians who wish to participate in Medicare Advantage plans must also participate with Medicare Part B.

Let’s all stand united against these cuts. At the same time, physicians  need to evaluate their practice’s financial situation and budget for the full projected 26.5 percent Medicare cut that will be effective Jan. 1 should Congress fail to act.

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