Can You “Opt Out” of Medicare?

No. Chiropractic Physicians are not allowed to opt-out of Medicare.

However, in an attempt to avoid the regulations, billing requirements, and documentation requirements, some chiropractic physicians attempt to find the loopholes in this prohibition. In short, the only way to avoid Medicare requirements is to not see a Medicare-eligible patient.

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Medicare has released a number of documents that clearly demonstrate that there is no way to avoid Medicare regulations and contract with a Medicare-eligible patient other than opting out; and chiropractors are not allowed to opt-out. Here is the short explanation:

1. Medicare requires physicians to submit claims for all covered services within one year from date of service (a few exceptions are listed below);
2. “Acute, chronic, and maintenance adjustments are all ‘covered’ services.”
3. Medicare requires that an ABN be obtained from a patient when rendering a covered service you feel will be denied;
4. Medicare requires claims submission when a Medicare-eligible patient requests that the service be billed; and

First, there is a distinct difference between a covered service and a service that is reimbursable. Below is an excerpt from document “ICN 906143 October 2013” from CMS:

“What are the covered chiropractic services under Medicare? Spinal manipulation is a covered service under Medicare. Acute, chronic, and maintenance adjustments are all “covered” services, but only acute and chronic services are considered active care and therefore, may be reimbursable. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment moves from corrective to supportive in nature, the treatment is then considered maintenance therapy.” [emphasis added]

In the same document, the following can be found:

“Do I have to submit a claim to Medicare, even though I know the service will be denied and the beneficiary has agreed to pay? This is one of the purposes of the Advance Beneficiary Notice (ABN). If you have a covered service you feel will be denied, you would present an ABN to the beneficiary. If they choose Option #1, yes, you would still be required to submit a claim. If the beneficiary chooses Option #2, then you would not be able to submit a claim.” [emphasis added]

Please note that Medicare ABN rules state that providers are prohibited from preselecting options on the ABN for the patient, and that “the patient or authorized representative is to personally select an option.” (Chapter 30 of the Medicare Claims Processing Manual, 70.4.4)

Additionally, in CMS’ Medicare Enrollment and Claim Submission Guidelines, CMS continues to emphasize the requirement to bill for the services rendered. The exceptions listed this document, are the only exceptions:

MEDICARE CLAIMS

A claim is defined as a request for payment for benefits or services received by a beneficiary. When you furnish covered services to Medicare beneficiaries, you are required to submit claims for your services and cannot charge beneficiaries for completing or filing Medicare claims. MACs monitor compliance with these requirements. Offenders may be subject to a Civil Monetary Penalty of up to $10,000 for each violation.

Exceptions to Mandatory Claim Filing

You are not required to file claims on behalf of Medicare beneficiaries when:

The claim is for services for which:

• Medicare is the secondary payer;
• The primary insurer’s payment is made directly to the beneficiary; and
• The beneficiary has not furnished the primary payment information needed to submit the Medicare secondary claim;
• The claim is for services furnished outside the United States (U.S.);
• The claim is for services initially paid by a third-party insurer who then files a Medicare claim to recoup what Medicare pays as the primary insurer (for example, indirect payment provisions);
• The claim is for other unusual services, which are evaluated by MACs on a case-by-case basis;
• The claim is for non-covered services, unless the beneficiary requests submission of a claim to Medicare (a supplemental insurer who pays for these services may require a Medicare claim denial notice prior to making payment);
• The beneficiary signed a Beneficiary Notice of Noncoverage, indicating that no claim should be filed for a specific item or service;
• You opted-out of the Medicare Program and entered into a private contract with the beneficiary (when you opt-out of Medicare and privately contract with a beneficiary for the purpose of furnishing items or services that would otherwise be covered, you cannot submit a claim for such services); or [Note: remember, Federal Law precludes chiropractors from opting out of Medicare]
• You have been excluded or debarred from the Medicare Program (when you have been excluded or debarred from the Medicare Program, you cannot submit a claim for your services).” [emphasis added]

These CMS documents, and others, clearly demonstrate that the only way for a chiropractic physician to avoid Medicare requirements is to avoid Medicare-eligible patients.