The Medicare 'Opt-Out' Process Explained
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At Trinity Heart and Vascular Group, we gladly welcome Medicare patients even though we don’t accept any insurance plans (including Medicare and Medicare Advantage plans).
If you participate with Medicare, we would be honored to care for your cardiovascular needs. To that end, we want to explain your options in regards to our Medicare status, and how that affects payments and reimbursements.
Since we don’t accept insurance of any kind, all of the medical providers at our practice have decided to ‘opt out’ of Medicare.
Any time a provider chooses to do this, it means that they do not wish to receive payments from the Medicare program, and thus ‘opt out’ of having contracts with straight Medicare plans and Medicare supplement plans.
If an eligible medical provider (including, but not limited to, a physician, physician assistant, or nurse practitioner) is able to opt out, he or she must:
- Be legally authorized to practice general medicine, surgery, dentistry, podiatry, optometry, or other specialties by the state in which such services are performed
- Submit an ‘Opt-Out’ Affidavit to CMS (Centers for Medicare and Medicaid Services) expressing his or her decision to opt-out
- Keep record of all Private Medicare Opt-Out Contracts that are signed by patients/beneficiaries
- Meet Medicare requirements for standard of care, and other legal requirements
What This Means for Medicare Patients
Since our providers have met the above requirements, our ‘opt out’ status means that:
Any Medicare patients who receive outpatient services at Trinity Heart and Vascular Group are required to pay ‘out of pocket’ for those services, and no one will be reimbursed by Medicare (neither the THVG medical provider nor the patient).
Any Medicare participant who become a patient at our practice will sign a private contract that states they agree to the following terms and conditions:
- We (THVG) will not submit claims to Medicare for any office visits or testing that are done in our office
- They (the patient) will not submit any claims to Medicare on their own, requesting reimbursement
In essence, the private contract between Trinity Heart and Vascular Group and our Medicare/Medicare Advantage patients states that neither party will submit a claim to Medicare for any services rendered in our offices.
This means that all services rendered by Trinity Heart and Vascular Group must be paid for by the patient. Medicare cannot be billed by anyone for these services.
This is a legally binding contract that not only involves Trinity Heart and Vascular Group and the patient, but the federal government as well.
[If either party violates the provisions by submitting a claim to Medicare, the violating party will be subjected to serious sanctions by the federal government.
We want to kindly yet strongly emphasize, that if you are a Medicare patient who chooses to sign the private contract in which you agree to pay our office directly, please do not submit a claim to Medicare for reimbursement, as we don’t want you to be fined or subject to legal action from the federal government.]
Even though you legally cannot submit a claim to Medicare requesting reimbursement for your office visits at Trinity Heart and Vascular Group, you can use your Medicare plan for any cardiac testing or lab work that is done by other providers who accept Medicare plans.
The Good News Regarding Testing and Prescribing
If you have a Medicare plan, and you prefer to have Medicare cover the cost of your cardiac testing, you can pay for your office visits directly at our office, and our providers will simply refer you to a facility of your choice that is a Medicare-participating provider.
This is part of our Hybrid Approach, where you pay for your office visits at our facility, but have the option to use your Medicare coverage for any testing that you need when it’s done at a facility that accepts Medicare plans.
In this approach, our orders for testing will be honored, and a claim for payment (for your testing) will be submitted to Medicare by the provider that we referred you to. The results from your test will be reported to our office, and you only have to pay for a follow-up office visit at our office since the test itself was completed at a different facility.
In summary, here are your options if you have Medicare, and you want to become a patient at Trinity Heart and Vascular Group:
1.) You pay out of pocket for your office visits, and also pay out of pocket for any cardiac testing that you need (none of which can be reimbursed by Medicare)
2.) You pay out of pocket for your office visits (which cannot be reimbursed by Medicare), but if you need cardiac testing, we will refer you to a facility that participates with Medicare, so that you can use your Medicare plan to cover the cost of your testing.
We understand that this approach is different, and you may have questions. If you want to know more about this process, please feel free to call us or email us, as we are more than happy to assist you.