Physician/Practitioner Who Has Never Enrolled in Medicare

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Here is what someone from AAFP said about the issue of physicians who have NEVER been enrolled in Medicare. I actually got it about 1 week ago but haven't remembered to post it to the listserve until now.Happy Thanksgiving to all! SetoSouth Pasadena, CABegin forwarded message:Date: November 18, 2008 8:43:39 AM PSTTo: Seto Subject: Re: Medicare Dr. Seto:I am responding to your subsequent e-mail, below, regarding Medicare and non-enrolled physicians. Your understanding and inferences from my first e-mail are correct, or at least consistent with my understanding of the relevant Medicare rules.Regarding your two additional questions:1. Practically speaking, a Medicare patient can see a non-enrolled physician and pay out of pocket as long as no claim ever gets submitted to Medicare by either the physician or patient, because absent a claim or some other inquiry to Medicare, Medicare would never be aware of the transaction. That said, as noted in my following answer to your second question, if Medicare ever did become aware of the transaction (eg. because the Medicare patient later tries to submit a claim on their own for care that was rendered), the physician could potentially be in trouble, so I would not recommend that a non-enrolled physician knowingly see a Medicare patient under these circumstances.2. A non-enrolled physician can potentially get in trouble for seeing a Medicare patient, particularly if the physician neglects to file a claim on the beneficiary's behalf. As noted in my reply to your original e-mail, the law essentially requires physicians to file claims on behalf of Medicare beneficiaries, and failure or refusal to do so could be considered a violation of the law. The only exception of which I am aware is in the situation where a physician "opts out" of Medicare. However, as you noted, this assumes the physician was "in" Medicare to begin with. I hope that this additional feedback is helpful. Please let me know if you have additional questions or if I may be of further assistance. Thank you.Kent J. Manager, Health Care Financing and Delivery Systems IssuesAmerican Academy of Family Physicians11400 Tomahawk Creek ParkwayLeawood, KS 66211-2672Phone: , ext. 4170Fax: E-mail: kmoore@... Seto 11/14/2008 1:05 PM >>>Dear Mr. ,Thank you very much for the extremely detailed and informative answer. So I understand that a physician who has never enrolled with Medicare is not recognized as either "participating" or "non-participating". By inference, I would assume that such a physician would not have to "opt out" since they were never "in" in the first place. And I understand that such a physician should not see Medicare patients, and expect to be paid by Medicare. If you don't mind I have two more questions for clarification which I hope you can answer:1. Can Medicare patients see this kind of physician and pay out of pocket as long as no claim gets submitted to Medicare by either the physician or patient?2. Can such a physician get in trouble (penalized/fined, etc) for seeing a Medicare patient (eg. if the Medicare patient tries to submit a claim on their own for care that was rendered)?Thanks for your attention. Seto, MDDr. Seto:I am responding to your e-mail below regarding Medicare. You asked if a physician who has never formally enrolled with Medicare is considered "non-participating" and subject to the rules and limits of non-participating status. You also asked how a physician in this situation would bill a patient who has Medicare. Specifically, you asked if the physician would have to submit a claim to Medicare, even if the physician had never enrolled in Medicare. Finally, you asked if such a physician has to follow the Medicare fee schedule. I will attempt to answer your questions.I consulted with staff in the Centers for Medicare and Medicaid Services (CMS) regional office in Kansas City. They advised that a physician who has never formally enrolled with Medicare is not recognized as either "participating" or "non-participating." Only a physician who has successfully enrolled in the Medicare program may elect to be either a "participating or "non-participating" physician and thereby subject to the payment rules of each category.CMS staff also advised me that, technically, a physician who is not enrolled in Medicare should not be seeing Medicare patients. In the event a non-enrolled physician sees and treats a patient who has Medicare, the physician cannot bill Medicare (since physicians, non- physician practitioners, and other health care suppliers must enroll in the Medicare program to be eligible to receive Medicare payment for covered services provided to Medicare beneficiaries). Section 1848(g)(4) of the Social Security Act does require the physician to file a claim on the beneficiary's behalf.If you desire a more official response, I would encourage you to contact the CMS regional office in your part of the country. Our membership information indicates that you live in California, and CMS has a regional office in San Francisco. You may contact that office as follows:Centers for Medicare and Medicaid Services90 7th Street, #5-300 (5W)San Francisco, California 94103-6706Phone: Fax: E-mail: ROSFOORA@... I hope that this information is helpful. Please let me know if you have additional questions or if I may be of further assistance. Thank you.Kent J. Manager, Health Care Financing and Delivery Systems IssuesAmerican Academy of Family Physicians11400 Tomahawk Creek ParkwayLeawood, KS 66211-2672Phone: , ext. 4170Fax: E-mail: kmoore@... 11/2/2008 5:12 PM >>>The following message was submitted by a user of the AAFP Web site:Name: SetoI have a question which you can hopefully answer. If a physician has never formally enrolled with Medicare, is the physician considered "non-participating" and subject to the rules and limits of non- participating status? How would a physician in this situation bill a patient who has Medicare? Do they have to submit a claim to Medicare even if they have never enrolled? Do they have to follow the Medicare fee schedule? Thanks for your assistance.