Physician/Practitioner Who Has Never Enrolled in Medicare

[Guest guest]

This issue has come up before -- what about the new graduates who have never enrolled in Medicare, but don't plan to sign up for Medicare.

Do they have to sign up to opt out or what?

I had a previous CMS Manual guideline, but it talked about UPIN's, so was dated.

Here is some more recent info - showing the changes from the old version.

It looks like you don't have to completely sign up for Medicare to then opt out.It appears you can just notify your regional Medicare carrier of your wishes and they will put you on a list.

For the full story on opting out and all the CMS guidelines -- check out Chapter 40 in the links below.

40 - Effect of Beneficiary Agreements Not to Use Medicare Coverage(Rev. 1, 10-01-03)B3-3044, PM-B-97-17

http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf

http://www.cms.hhs.gov/Transmittals/Downloads/R92BP.pdf

40.13 - Physician/Practitioner Who Has Never Enrolled in Medicare

(Rev. 92; Issued: 06-27-08; Effective/Implementation Date: 09-29-08)

For a physician/practitioner who has never enrolled in the Medicare program and wishes to opt out of Medicare, the physician/practitioner must provide the carrier with a National Provider Identifier (NPI). The carrier must annotate its in-house provider file that the physician/practitioner has opted out of the program. The carrier can get the full name, address, license number, and tax identification number from the physician’s/practitioner’s opt out affidavit. All other data requirements should be developed from other data sources (e.g., the American Medical Association, State Licensing Board, etc.). 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 the physician/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 an NPI.

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.

Locke, MD