Am I obligated to enroll?
Don’t Want to Enroll in Medicare?!?
You don’t HAVE to – but you are expected to make a choice between two (three?) options and register yourself.
The two choices of Medicare provider enrollment for (most) behavioral health clinicians are:
- Enroll as a “participating” provider
- Opt out
The government expects all Medicare-eligible clinicians to make a choice and enroll accordingly.
What the government DOESN’T want, is for clinicians to refrain from choosing. There can be negative consequences to staying outside the system, which I discuss below.
Counselors and Marriage-Family Therapists, in 2024 this includes YOU!
For the uninitiated, Medicare seems designed to frustrate, with all its acronyms, lingo, and peculiarities. But it doesn’t have to be this way.
The Medicare Provider Enrollment categories
Participating – There is no “credentialing” in Medicare. Compared to a private insurer, it’s a relatively straightforward and short process. (Keyword here being relatively…!)
To enroll on paper, you file the appropriate forms:
855I (for individuals)
855B (groups)
588 (electronic funds transfer is required)
460 (participation agreement)
Or, you complete the same information on PECOS – Medicare’s online enrollment system.
The Medicare provider enrollment process takes 30-45 days. Once your application is received, an analyst scrutinizes it for completeness. If something is missing or incomplete, you will receive a letter outlining what they need, and you’re given 30 days to resolve the deficiency.
If the application is not completed to Medicare’s standards, they will reject your application and you’ll have to re-apply (if you still want to enroll as a Medicare provider).
There may also be a site visit. If you work mostly remotely, or in an office owned by another entity, call the Provider Enrollment department at your MAC (Medicare Administrative Contractor) to ask how to proceed. Site visits are a negative consequence of past fraud.
Medicare needs to ensure you are a legitimate business. If you are using a “virtual” or shared office space for seeing clients in person, contact Medicare provider enrollment to ask for advice.
For those that pass: your effective date of participation will be 30 days PRIOR to the receipt date of the successful enrollment application. (Counselors and MFTs: this will not be before 1/1/24).
The letter you receive will contain at least one “PTAN” (Provider Transaction Access Number). The number of PTANs you receive will depend on whether you bill under a type 1 or type 2 NPI, and/or if you provide services in different fee areas, and/or have signed a “reassignment” to allow a larger group or facility to bill for your services. Those PTANs are very important – you will need them whenever you call Medicare, and to enroll for electronic transactions.
To bill, hook your billing system up to send claims electronically…and off you go! (Medicare does not accept paper claims except in special circumstances, or fewer than a very small number each quarter).
Participating Clinicians are required to:
- Submit claims for clients.
- Accept the Medicare allowable rate as payment in full.
- Only collect deductible/coinsurance from your client. (No superbills)
Non-Participating – I‘ll describe it here, because psychiatrists are allowed to enroll in this category.
Nurse practitioners, psychologists, social workers, marriage/family therapists, and counselors are statutorily NOT allowed to be non-participating!!!
That said, there have been instances reported of employees at Medicare contractors telling non-psychiatrists that they can enroll as non-par, and even enrolling them as non-par. So I don’t have a definitive answer – take that one up with the Powers That Be.
To enroll as a non-participating Medicare provider, you will NOT sign the CMS form 460. The lack of this form is what enrolls you as non-par. Otherwise, the enrollment process is identical.
Non-participating providers are allowed to charge more. Specifically, in a Medicare mathematical sleight of hand, 10% more. Here’s how it works. When Medicare processes your claim, they will allow 95% of the amount paid to participating providers. The non-participating clinician is then permitted to add 15%, with the total net gain, therefore, being 10%. The 15% is what is referred to as the “limiting charge” – the amount that a non-par provider can add on top of what Medicare allows.*
*Some states, such as New York, restrict the limiting charge. Contact a licensed healthcare attorney in your state.
You MUST file the claims for your client. However, you do NOT have to accept the assignment. (Accepting assignment = Medicare pays you). You are allowed to collect in full at the time of service: the Medicare allowed amount + the limiting charge. Upon receipt of a non-assigned claim, Medicare will reimburse your client directly.
Note that Medicare will also not cross over (forward) non-par claims to a supplemental or secondary insurer.
Unlike with a commercial or a Medicare Advantage plan, the benefits to your client are NOT reduced if you are non-participating. Medicare Part B pays 80% after the deductible, regardless of the clinician’s status. However, your client’s supplement or secondary plan may not reimburse them for the limiting charge.
Still want absolutely NOTHING to do with Medicare?
Then you need to Opt-Out! Opting out is the third enrollment category.
Opting out is the simplest of all. There is a short form you file to Medicare, called an affidavit. Each Medicare contractor has one available for download on their website.
Opting out is an all-or-nothing proposition: It applies to all Medicare beneficiaries. If you currently have clients with Medicare, they will lose their benefits too – not just your new clients. Want to keep your current Medicare clients, just don’t want any more?
Tip: close your practice to new clients rather than opt out. This is legit.
Opting out covers all services/procedures covered by Medicare.
Opting out puts your NPI on a publicly searchable list and applies to ALL practice locations. So know this…
If you’re out – YOU’RE OUT!
You cannot be opted out in your private practice but then accept Medicare clients at a group or facility.
What if I opt out but want to re-enroll in the future?
You can! There is never a barrier to changing your status, although naturally, there are a few rules… (hey, it’s Medicare!)
- For clinicians who are in their first opt-out cycle, there is a one-time “buyer’s remorse,” or Early Termination. You can cancel your opt-out enrollment within the first 90 days of your opt-out date. This is not available, ever again.
- Be mindful of when your two-year cycle ends. You can only re-enroll at the end of the two years. You must re-enroll no later than 30 days before the start of the next two-year cycle.
Note for clinicians who prescribe medication: As an opt-out provider, the drugs you prescribe will ONLY be covered by Medicare if you stay enrolled with your privileges restricted to order, certify, & prescribe. This is an option.
The Private Contract
Most Medicare contractors have one available on their website as well. My advice is to download it, and don’t modify it except to cut & paste the verbiage onto your letterhead or into your client electronic portal.
It’s important for you to know what it says.
A lot of things, some of which are obvious enough that I do not need to rehash them. The main points are the client,,,
- agrees to pay & agrees not to file for reimbursement.
- understands Medicare, Medicare Advantage, and/or supplement plans will not pay.
- understands Medicare limits on charges do not apply.
- understands that the services could be covered by Medicare, if obtained from a provider who had not opted out.
- acknowledges this agreement is voluntary.
Do not take what’s written here as everything you need, if you want to opt-out. There is more to learn. Go to a Medicare contractor’s website to download their form.
Opt-out private contracts MUST be in writing and kept on file in your paper chart or EMR. As with anything else, if it isn’t documented – it didn’t happen.
Can I use a Good Faith Estimate instead?
NO. “Good faith estimates” do not apply to Medicare clients.
What happens if I stay unenrolled?
They don’t examine lists of licensed professionals and compare them against enrollment databases.
All it takes is one Medicare client who pays you, obtains a superbill, and then files for reimbursement. You might receive an extremely frightening letter.
The letter will state:
Medicare guidelines outlined in Section 1848(g)(4) of the Social Security Act, require the physician or supplier to file a claim on the beneficiary’s behalf for service(s) rendered to a Medicare beneficiary that may be covered. … Physicians … who fail to submit a claim or who impose a charge for completing the claim can be subject to sanctions and/or monetary penalties.
NOW WHAT?
DON’T IGNORE IT!
If you’re unaffiliated with Medicare and you’ve received the above letter, choose an enrollment category and get onboard. They will not prosecute you for a first offense, IF you take prompt action. Enrolling in one of the above categories will demonstrate your compliance going forward.
You may be required to refund fees collected from your client(s) for sessions that didn’t follow Medicare’s rules.
Where is this written? LEGALESE – click at your own peril!
Medicare IS manageable – But you don’t have to go it alone!
For expert assistance with Medicare or any other billing issue, schedule a consultation anytime!
