Medicare Private Billing Rules
IMPORTANT-NEW PATIENTS
Prior to your first meeting with the doctor, please download the PDF documents from the links below, print them, sign them, and bring them with you. Thank you.
Is a Patient Allowed to File on Her Own for Reimbursement of Services of an Opted-Out Provider?
No, a patient is not allowed to file for reimbursement of services from an opted-out provider. When a provider opts out of Medicare, neither the provider nor the patient can submit a bill to Medicare for reimbursement. This is a condition of the opt-out agreement that lasts for two consecutive years [2]. An opted-out physician may set their own fees but is prohibited from submitting claims to Medicare or receiving any payment from Medicare [5]. This arrangement also means that Medicare patients treated by an opted-out provider must enter into a private contract with the provider and are responsible for all charges without Medicare reimbursement.
Is a Patient Allowed to File on Her Own for Reimbursement of Services to Her Private Insurance or Secondary Gap Insurance of a CMS/Medicare Opted-Out Provider
Yes, a patient can potentially file for reimbursement from their private insurance or secondary gap insurance for services received from a CMS/Medicare opted-out provider. However, this depends on the terms and conditions of the patient's private or secondary insurance policy. When a provider opts out of Medicare, they enter into a private contract with each Medicare patient, which means Medicare will not reimburse any services provided by that provider [1][5]. The ability to file a claim with private insurance or secondary insurance is separate from Medicare's rules. Patients should consult their insurance policy or contact their insurance provider to understand if services from a Medicare opted-out provider are covered and the process for filing such claims.
Sources
cms.gov - Manage Your Enrollment
investopedia.com - What to Do When Your Doctor Doesn't Take Medicare
medicareadvocacy.org - Part D / Prescription Drug Benefits
medicareinteractive.org - Participating, non-participating, and opt-out providers
noridianmedicare.com - Opt Out of Medicare
palmettogba.com - Providers Opting Out of Medicare: Private Contracting