Physician/Practitioner Who Has Never Enrolled in Medicare --> RE: medicare status - are there really 4?

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,Below into talks about getting a UPIN number (as opposed to NPI) so might be outdated -- this is from a previous post on the topic at hand -- Physician/Practitioner Who Has Never Enrolled in MedicareMight give some idea of what Medicare does -- but might need to do some more digging.

==============================================www.cms.hhs.gov/Manuals/downloads/bp102c15.pdf40.13 - Physician/Practitioner Who Has Never Enrolled in Medicare(Rev. 1, 10-01-03)B3-3044.13For a physician/practitioner who has never enrolled in the Medicare program and wishes to opt out of Medicare, the carrier must provide the physician/practitioner with a Unique Physician Identification Number (UPIN). It can get the full name, address, license number, and tax identification number from this affidavit. All other data requirements should be developed from other data sources (e.g., the American Medical Association, State Licensing Board, etc.). The carrier must annotate its in-house provider file and update the UPIN Registry that the physician/practitioner has opted out of the program.The physician/practitioner must not receive payment during the opt-out period (except in the case of emergency or urgent care services). If the carrier needs additional data elements and cannot obtain that information from another source, it may contact thephysician/practitioner directly. It must notify the physician or practitioner that in order to refer or order services for a Medicare patient, the physician or practitioner must have a UPIN.If an opt-out physician/practitioner provides emergency or urgent care service to a beneficiary who has not signed a private contact with the physician or practitioner and the physician/practitioner submits an assigned claim, the physician or practitioner must complete Form CMS-855 and enroll in the Medicare program before receiving reimbursement. Under a similar circumstance, if the physician or practitioner submits an unassigned claim, the carrier must pay the beneficiary directly without requiring a completed Form CMS-855. It may use the information from the affidavit to begin the enrollment process. www.cms.hhs.gov/Manuals/downloads/bp102c15.pdf <http://www.cms.hhs.gov/Manuals/downloads/bp102c15.pdf>40.11 - Failure to Maintain Opt-Out(Rev. 1, 10-01-03)B3-3044.11A physician/practitioner fails to maintain opt-out under this section if during the opt-outperiod one of the following occurs:• The physician/practitioner has filed an affidavit in accordance with §40.9 and hassigned private contracts in accordance with §40.8 but,• The physician/practitioner knowingly and willfully submits a claim for Medicarepayment (except as provided in §40.28); or• Receives Medicare payment directly or indirectly for Medicare-covered servicesfurnished to a Medicare beneficiary (except as provided in §40.28).• The physician/practitioner fails to enter into private contracts with Medicarebeneficiaries for the purpose of furnishing items and services that wouldotherwise be covered by Medicare, or enters into private contracts that fail tomeet the specifications of §40.8; or• The physician/practitioner fails to comply with the provisions of §40.28regarding billing for emergency care services or urgent care services; or• The physician/practitioner fails to retain a copy of each private contract that thephysician/practitioner has entered into for the duration of the opt-out period forwhich the contracts are applicable or fails to permit CMS to inspect them uponrequest.If a physician/practitioner fails to maintain opt-out in accordance with the aboveparagraphs of this section, and fails to demonstrate within 45 days of a notice from thecarrier of a violation of the first paragraph of this section that the physician/practitionerhas taken good faith efforts to maintain opt-out (including by refunding amounts inexcess of the charge limits to the beneficiaries with whom the physician/practitioner didnot sign a private contract), the following will result effective 46 days after the date of thenotice, but only for the remainder of the opt-out period. (However, if thephysician/practitioner did not privately contract and refunds coverage, thephysician/practitioner may still maintain the opt-out):• All of the private contracts between the physician/practitioner and Medicarebeneficiaries are deemed null and void.• The physician’s or practitioner’s opt-out of Medicare is nullified.• The physician or practitioner must submit claims to Medicare for all Medicarecovereditems and services furnished to Medicare beneficiaries.• The physician or practitioner or beneficiary will not receive Medicare paymenton Medicare claims for the remainder of the opt-out period, except as statedabove.• The physician or practitioner is subject to the limiting charge provisions as statedin §40.10.• The practitioner may not reassign any claim except as provided in the MedicareClaims Processing Manual, Chapter 1, “General Billing Requirements,”§30.2.13. <http://30.2.13./>• The practitioner may neither bill nor collect any amount from the beneficiaryexcept for applicable deductible and coinsurance amounts.• The physician or practitioner may not attempt to once more meet the criteria forproperly opting out until the 2-year opt-out period expires.40.12 - Actions to Take in Cases of Failure to Maintain Opt-Out(Rev. 1, 10-01-03)B3-3044.12If the carrier becomes aware that the physician/practitioner has failed to maintain opt-outas indicated in §40.11, it must send the physician/practitioner a letter advising thephysician/practitioner that it has received a claim and believes that the physician/practitioner may have inadvertently failed to maintain opt-out. It must describe thesituation in §40.11 that it believes exists and its basis for its belief. It must ask thephysician or practitioner to provide it with an explanation within 45 days of whathappened and how the physician or practitioner will resolve it. (See the Medicare ClaimsProcessing Manual, Chapter 1, “General Billing Requirements,” §70.6, and the MedicareProgram Integrity Manual for action when responses are not received within 45 days).If the carrier received a claim from the opt-out physician/practitioner, it must ask thephysician/practitioner if the received claim was: (a) an emergency or urgent situation,with missing documentation, or ( filed in error. When the reason for the letter is thatthe physician/practitioner filed a claim that the physician/practitioner did not identify asan emergency or urgent care service, the carrier must request that thephysician/practitioner submit the following information with thephysician’s/practitioner’s response:• Emergency/urgent care documentation if the claim was for a service furnished inan emergency or urgent situation but included no documentation to that effect;and/or• If the claim was filed in error, the carrier must ask the physician/practitioner toexplain whether the filing was an isolated incident or a systematic problemaffecting a number of claims.In the case of any potential failure to maintain opt-out (including but not limited toimproper submission of a claim), the carrier must explain in its request to the physician orpractitioner that it would like to resolve this matter as soon as possible. It must instructthe physician/practitioner to provide the information it requested within 45 days of thedate of its development letter. It must provide the physician or practitioner with the nameand telephone number of a contact person in case they have any questions.If the violation was due to a systems problem, the carrier must ask the physician orpractitioner to include with his or her response an explanation of the actions being takento correct the problem and when the physician or practitioner expects the system error tobe fixed. If the violation persists beyond the time period indicated in the physician’s orpractitioner’s response, the carrier must contact the physician or practitioner again toascertain why the problem still exists and when the physician or practitioner expects tohave it corrected. It must repeat this process until the system problem is corrected.Also, in the carrier’s development request, it must advise the physician or practitionerthat if no response is received by the due date, the carrier will assume that there has beenno correction of the failure to maintain opt-out and that this could result in adetermination that the physician/practitioner is once again subject to Medicare rules.In the case of wrongly filed claims, the carrier must hold the claim and any others itreceives from the physician or practitioner in suspense until it hears from the physician orpractitioner or the response date lapses. In this case, if the physician or practitionerresponds that the claim was filed in error, the carrier must continue processing the claim,deny the claim, and send the physician or practitioner the appropriate Remittance Adviceand send the beneficiary a Medicare Summary Notice (MSN) with the appropriatelanguage explaining that the claim was submitted erroneously and the beneficiary isresponsible for the physician’s or practitioner’s charge. In other words, the limitingcharge provision does not apply and the beneficiary is responsible for all charges. Thisprocess will apply to all claims until the physician or practitioner is able to get theproblem fixed.If the carrier does not receive a response from the physician or practitioner by thedevelopment letter due date or if it is determined that the opt-out physician or practitionerknowingly and willfully failed to maintain opt-out, it must notify the physician orpractitioner that the effects of failure to maintain opt-out specified in §40.11 apply. Itmust formally notify the physician/practitioner of this determination and of therules that again apply (e.g., mandatory submission of claims, limiting charge, etc.).It must specifically include in this letter each of the effects of failing to opt out that areidentified in §40.11.The act of claims submission by the beneficiary for an item or service provided by aphysician or practitioner who has opted out is not a violation by the physician orpractitioner and does not nullify the contract with the beneficiary. However, if there arewhat the carrier considers to be a substantial number of claims submissions bybeneficiaries for items or services by an opt-out physician or practitioner, it mustinvestigate to ensure that contracts between the physician or practitioner and thebeneficiaries exist and that the terms of the contracts meet the Medicare statutoryrequirements outlined in this instruction. If noncompliance with the opt-out affidavit isdetermined, it must develop claims submission or limiting charge violation cases, asappropriate, based on its findings.In cases in which the beneficiary files an appeal of the denial of a beneficiary-filed claimfor services from an opt-out physician or practitioner, and alleges that there was noprivate contract, the carrier must ask the physician/practitioner to provide it with a copyof the private contract, but only if the beneficiary authorizes the carrier to do so. Wherethe physician or practitioner does not provide a copy of a private contract that was signedby the beneficiary before the service was furnished, the carrier must make payment to thebeneficiary and proceed as described above.40.34 - Renewal of Opt-Out(Rev. 1, 10-01-03)B3-3044.34A physician or practitioner may renew an opt out without interruption by filing anaffidavit with each carrier to which an affidavit was submitted for the first opt out (asspecified in §40.9), and to each carrier to which a claim was submitted under §40.28during the previous opt out period, provided the affidavits are filed within 30 days afterthe current opt-out period expires.40.35 - Early Termination of Opt-Out(Rev. 1, 10-01-03)B3-3044.35If a physician or practitioner changes his or her mind after the carrier has approved theaffidavit, the opt-out may be terminated within 90 days of the effective date of theaffidavit. To properly terminate an opt out, a physician or practitioner must:• Not have previously opted out of Medicare;• Notify all Medicare carriers, with which the physician or practitioner filed anaffidavit, of the termination of the opt-out no later than 90 days after the effectivedate of the opt-out period;• Refund to each beneficiary with whom the physician or practitioner has privatelycontracted all payment collected in excess of:º The Medicare limiting charge (in the case of physicians orpractitioners);orº The deductible and coinsurance (in the case of practitioners).• Notify all beneficiaries with whom the physician or practitioner entered intoprivate contracts of the physician’s or practitioner’s decision to terminate opt outand of the beneficiaries’ rights to have claims filed on their behalf with Medicarefor services furnished during the period between the effective date of the opt-outand the effective date of the termination of the opt-out period.When the physician or practitioner properly terminates opt-out in accordance with thesecond bullet above, the physician or practitioner will be reinstated in Medicare as ifthere had been no opt-out, and the provision of §40.3 must not apply unless the physicianor practitioner subsequently properly opts out.=================================================40.1 - Private Contracts Between Beneficiaries andPhysicians/Practitioners(Rev. 1, 10-01-03)B3-3044.1Section 1802 of the Act, as amended by §4507 of the BBA of 1997, permits aphysician/practitioner to opt out of Medicare and enter into private contracts withMedicare beneficiaries if specific requirements of this instruction are met.40.2 - General Rules of Private Contracts(Rev. 1, 10-01-03)B3-3044.2The following rules apply to physicians/practitioners who opt out of Medicare:• A physician/practitioner may enter into one or more private contracts withMedicare beneficiaries for the purpose of furnishing items or services that wouldotherwise be covered by Medicare (provided the conditions in §40.1 are met).• A physician/practitioner who enters into at least one private contract with aMedicare beneficiary (under the conditions of §40.1) and who submits one ormore affidavits in accordance with §40.9, opts out of Medicare for a 2-year periodunless the opt-out is terminated early according to §40.35 or unless thephysician/practitioner fails to maintain opt-out. (See §40.11.) The physician’s orpractitioner’s opt out may be renewed for subsequent 2-year periods.• Both the private contracts described in the first paragraph of this section and thephysician’s or practitioner’s opt out described in the second paragraph of thissection are null and void if the physician/practitioner fails to properly opt out inaccordance with the conditions of these instructions.• Both the private contracts described in the first paragraph of this section and thephysician’s or practitioner’s opt out described in the second paragraph of thissection are null and void for the remainder of the opt-out period if thephysician/practitioner fails to remain in compliance with the conditions of theseinstructions during the opt-out period.• Services furnished under private contracts meeting the requirements of theseinstructions are not covered services under Medicare, and no Medicare paymentwill be made for such services either directly or indirectly.40.5 - When a Physician or Practitioner Opts Out of Medicare(Rev. 1, 10-01-03)B3-3044.5When a physician/practitioner opts out of Medicare, Medicare covers no servicesprovided by that individual and no Medicare payment can be made to that physician orpractitioner directly or on a capitated basis. Additionally, no Medicare payment may bemade to a beneficiary for items or services provided directly by a physician orpractitioner who has opted out of the program.Under the statute, the physician/practitioner cannot choose to opt out of Medicare forsome Medicare beneficiaries but not others; or for some services but not others. Thephysician/practitioner who chooses to opt out of Medicare may provide covered care toMedicare beneficiaries only through private agreements.Medicare will make payment for covered, medically necessary services that are orderedby a physician/practitioner who has opted out of Medicare if the ordering physician/practitioner has acquired a unique provider identification number (UPIN) from Medicareand provided that the services are not furnished by another physician/practitioner who hasalso opted out. For example, if an opt-out physician/practitioner admits a beneficiary to ahospital, Medicare will reimburse the hospital for medically necessary care.40.7 - Definition of a Private Contract(Rev. 1, 10-01-03)B3-3044.7A “private contract” is a contract between a Medicare beneficiary and a physician orother practitioner who has opted out of Medicare for two years for all covered items andservices the physician/practitioner furnishes to Medicare beneficiaries. In a privatecontract, the Medicare beneficiary agrees to give up Medicare payment for servicesfurnished by the physician/practitioner and to pay the physician/practitioner withoutregard to any limits that would otherwise apply to what the physician/practitioner couldcharge. Pursuant to the statute, once a physician/practitioner files an affidavit notifyingthe Medicare carrier that the he/she has opted out of Medicare, the physician/practitioneris out of Medicare for two years from the date the affidavit is signed (unless the opt-out isterminated early according to §40.35, or unless the he/she fails to maintain opt-out (See§40.11)). After those two years are over, a physician/practitioner could elect to return toMedicare or to opt out again. A beneficiary who signs a private contract with aphysician/practitioner is not precluded from receiving services from other physicians andpractitioners who have not opted out of Medicare.Physicians or practitioners who provide services to Medicare beneficiaries enrolled in thenew Medical Savings Account (MSA) demonstration created by the BBA of 1997 are notrequired to enter into a private contract with those beneficiaries and to opt out ofMedicare under §1802 of the Act. Locke, MD