CMS: No Policy Change on M.D.s Who Opt Out of Medicare

There has been no change in the Centers for Medicare and Medicaid Services (CMS) policy regarding the ability of physicians who have opted out of Medicare to have their referrals or prescriptions for private-contract Medicare patients covered by the program.

CMS has assured APA that in fact physicians who have opted out of the federal program can still have referrals and prescriptions for privately contracted Medicare patients covered, said Ellen Jaffe, director of the APA Practice Management HelpLine and the Medicare specialist in APA’s Office of Healthcare Systems and Financing.

Jaffe said the matter was a subject of some confusion and concern on the part of APA members after a July 9 report in the Wall Street Journal quoting from a report by the Office of the Inspector General (OIG) about questionable claims and possible fraud in the Medicare program seemed to indicate that CMS had changed its policy on physicians who opt out of Medicare. The article was titled, “Report Raises Red Flags on Medicare Lab Billing: Questionable Payments Shows Health Program’s Vulnerability to Abuse.”

But the confusion stemmed from what appears to be a typographical error in a portion of the OIG report quoted by the Journal that stated, “the agency began denying claims for Part B clinical lab services if the provider who ordered or referred the service was not enrolled in Medicare or had obtained `opt-out’ status.”

Jaffe contacted CMS after calls to the HelpLine came in from APA members and was assured that physicians who have opted out are indeed permitted to order and refer. A CMS official told Jaffe that what the OIG report was intended to convey is that claim denials will be issued to physicians who have not submitted a valid opt-out affidavit, and that the pertinent sentence in the OIG report should have read: “the agency began denying claims for Part B clinical lab services if the provider who ordered or referred the service was not enrolled in Medicare or had not obtained ‘opt-out’ status.”

“The important point is that there has been no change in CMS policy with regard to physicians who have opted out,” Jaffe told Psychiatric News. “They can still have prescription orders and referrals for privately contracted Medicare patients covered by the program.” ■