Can a Physical Therapist or Chiropractor “Opt-Out” of Medicare?

As of November 1, 2019,  a physical therapist or chiropractor,  are unable to “opt-out” out Medicare. If you look at this chart you will see that physical therapists and chiropractors are not listed as providers who are able to opt out. The Medicare Benefit Policy Manual: Chapter 15 Section 40.4 states Physical therapists in independent practice and occupational therapists in independent practice cannot opt out because they are not within the opt out law’s definition of either a “physician” or “practitioner”. A non-opt-out provider, is required to submit a claim for any item or service that is, or may be, covered by Medicare.

The only situation in which they are not required to submit claims to Medicare for covered services is where a beneficiary or the beneficiary’s legal representative refuses, of his/her own free will, to authorize the submission of a bill to Medicare.

In some circumstances, a non-opt-out provider is required to provide an Advance Beneficiary Notice of Noncoverage (ABN) to the beneficiary prior to rendering an item or service that is usually covered by Medicare but may not be covered in this particular case. The ABN notifies the beneficiary that Medicare will likely deny the claim and prompts the beneficiary to choose whether or not he/she will accept liability for the full cost of the services if Medicare does not pay. The beneficiary also indicates on the ABN whether or not a claim should be submitted to Medicare. Providers and suppliers must follow the beneficiary’s directive for claim submission as indicated on the ABN. Providers and suppliers will not violate the mandatory claim submission rules of §1848(g)(4) of the Social Security Act when a claim is not submitted per a beneficiary’s written request on an ABN. Where a valid ABN is given and a claim is submitted, subsequent denial of the claim relieves the non-opt-out physical therapist of the limitations on charges that would apply if the services were covered. If you are providing services that are never covered by Medicare it is not mandatory for your to provide Medicare beneficiaries with ABNs for these services but you should create your own written notice informing them of the costs for service and the fact that Medicare will not cover any part of those costs.

Because Medicare’s rules do not apply to items or services that are categorically not covered by Medicare, a private contract is not needed to furnish such items or services to Medicare beneficiaries, and Medicare’s claims filing rules and limits on charges do not apply to such items or services. For example, because Medicare does not cover hearing aids, a physician or practitioner, or other supplier may furnish a hearing aid to a Medicare beneficiary and would not be required to file a claim with Medicare; further, the physician, practitioner, or other supplier would not be subject to any Medicare limit on the amount they could collect for the hearing aid. If the item or service is one that is not categorically excluded from coverage by Medicare, but may be non-covered in a given case (for example, it is covered only where certain clinical criteria are met and there is a question as to whether the criteria are met), a non-opt-out physical therapist or chiropractor is not relieved of his or her obligation to file a claim with Medicare.

If you have no relationship with Medicare, meaning that you are not enrolled as a “Participating Provider” nor as a “Non-Participating Provider” it would only be acceptable to accept self-payments from a Medicare Beneficiary if it is a for a service that would not be covered by Medicare (i.e. not reasonable and medically necessary) or if a beneficiary or the beneficiary’s legal representative refuses, of his/her own free will, to authorize the submission of a bill to Medicare.

*************

It should be noted that I am not your lawyer (unless you have presently retained my services through a retainer agreement). This post is not intended as legal advice, it is purely educational and informational, and no attorney-client relationship shall result after reading it. Please consult your own attorney for legal advice. If you do not have one and would like to retain my legal services, please contact me using the contact information listed above.

All information and references made to laws, rules, regulations, and advisory opinions were accurate based on the law as it existed at this time, but laws are constantly evolving. Please contact me to be sure that the law which will govern your business is current. Thank you.