Opting Out of the Medicare System (Or Not)

Written by Tom Necela, DC, CPC, CPMA, CCP-P

As a speaker at events I am often asked questions after my presentations regarding billing and coding, when voices drop low I know it’s time for questions about Medicare. Frustration ramps up and it’s time to discuss opting out.

For those of you who don’t like Medicare, you probably have considered “not playing their game.” Unfortunately, they have rules for you too. Namely:

• Chiropractors cannot opt out of Medicare. As DC’s we have a “special” status in the Medicare system; we are neither full-fledged physicians (like MD’s) but we are also more than practitioners (like PT’s).To quote the Medicare Benefit Policy Manual“The opt out law does not define “physician” to include chiropractors; therefore, they may not opt out of Medicare and provide services under private contract.” (Ch 15, Section 40.4).Basically, this means youcannot leave the Medicare family. I know that sounds a lot like the mentality of certain “agreements” made with gangs, loan sharks, drug dealers or the mob, it is an accurate comparison. The coffin, provided you are in it legitimately and permanently, is one notable exception to “opting out” of Medicare. But at that point, your participation in Medicare is so limited it is probably a non-issue.
• Whether or Not You ThinkYou are In Medicare, You are in Medicare. Remember that lovely little thing called the NPI that was instituted a few years back? With this number, each and every payer can (and does) track your every move – including Medicare. So, even if you are blatantly trying to ignore Medicare by “staying under the radar” and providing all your services in exchange for chickens, lawn care or for free out of the kindness of your heart, IF you have provided a chiropractic adjustment to a Medicare beneficiary you are in the Medicare system. Or at least you should be.Therefore, the fact that you didn’t complete a provider application, that you don’t submit any claims to Medicare or that you can’t find anything from Medicare that indicates you are a provider, you are still subject to Medicare rules and regulations. Practically speaking, you have provider services to a Medicare beneficiary via a “private contract” (as defined in the Medicare Benefit Policy Manual, Ch. 15, Section 40.7). Unfortunately, as a chiropractor you are not allowed to have a private contract with Medicare patients because only those who can opt out can legally establish a private contract Therefore, you are in Medicare, but not playing by Medicare’s rules. Likely, you are in trouble as well and you should fix this situation immediately, as Medicare penalties are not for the faint hearted.

For those of you who have been operating inefficiently, illegally or somewhere in between and have been brought to light by this post, I don’t need to hear your confession or defense of why you have been in the dark about this. Instead, it may be time to take concrete steps towards more closely evaluating your billing department (whether in-house or outsourced), as they should know and/or catch some of this for you.