Opting-Out of Medicare and Other Insurance Companies

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1 I S S U E Fall PracticePerspectives The National Association of Social Workers 750 First Street NE Suite 800 Mirean Coleman MSW, LICSW, CT Clinical Manager mcoleman.nasw@socialworkers.org Washington, DC SocialWorkers.org Opting-Out of Medicare and Other Insurance Companies 2017 National Association of Social Workers. All Rights Reserved. NASW members are seeking reimbursement clarifications when performing psychotherapy services to Medicare Part B beneficiaries who do not wish to use their Medicare benefits. In such situations, a clinical social worker may opt-out of Medicare. This means that the clinical social worker cannot bill Medicare for any services they perform. Instead, reimbursement is received from the Medicare beneficiary under the terms of a private contract. Private Contract The Balanced Budget Act of 1997, section 4507, defines a private contract as an agreement between a Medicare beneficiary and a clinical social worker or other practitioner who has opted-out of Medicare for all covered services she or he furnishes to Medicare beneficiaries. In the contract, the patient agrees to give up Medicare payment for services furnished by the clinical social worker and pay the clinical social worker without regard to any limits established by the Medicare fee schedule. For example, if Medicare reimburses $60 for a 45 minute psychotherapy session, then a customary rate of $100 may be charged. The private contract must be signed and dated by both the clinical social worker and patient before services are furnished. It must also state without ambiguity that by signing the contract, the patient agrees to the following: Gives up all Medicare coverage and payment for services furnished by the clinical social worker Will not bill Medicare nor ask the clinical social worker to bill Medicare Is liable for charges of the clinical social worker without any limits that would otherwise be imposed by Medicare Acknowledges that Medigap may not make payment for services and other supplementary insurers may not pay either Acknowledges that she or he has the right to receive services from a clinical

2 NASW members are seeking reimbursement clarifications when performing psychotherapy services to Medicare Part B beneficiaries who do not wish to use their Medicare benefits. In such situations, a clinical social worker may opt-out of Medicare. social worker or other practitioner for whom Medicare coverage and payment would be available Acknowledges that she or he has received a copy of the private contract. The private contract should also State the effective and expiration dates of the opt-out period Be signed by the patient and the clinical social worker. Some MACs require a witness Be retained by the clinical social worker and made available to the Centers for Medicare and Medicaid Services (CMS) upon request. The contract becomes invalid if it is entered into by a Medicare beneficiary when she or he is facing an emergency or urgent health situation. Opting-Out A clinical social worker who is a Medicare provider must send an opt-out affidavit to their local Medicare Administrative Contractor (MAC) before entering into a private contract with a Medicare patient. A clinical social worker who is not a Medicare provider can opt-out at any time, while a participating clinical social work Medicare provider must send the affidavit to the carrier 30 days before the beginning of the quarter when their opt-out period will begin. Medicare quarters begin on January 1, April 1, July 1, and October 1. To avoid reimbursement problems, clinical social workers who choose to opt-out of Medicare should provide services to Medicare beneficiaries only through private contracts. To have a private contract, the clinical social worker must first opt-out of Medicare by filing an affidavit with all MACs to which she or he would submit claims. The affidavit must be filed no later than 10 days after entering into the first private contract. The affidavit should Provide that the clinical social worker will not submit any claims to Medicare beginning on the date the affidavit is signed Provide that the clinical social worker will not receive any Medicare payment for any services provided to Medicare beneficiaries Identify the clinical social worker s National Provider Identification number and Medicare provider number Be signed and dated by the clinical social worker. Emergency Situations Medicare payment may be made for emergency psychotherapy services performed by an opt-out clinical social worker who has not signed a private contract with the Medicare beneficiary requiring the service. In this circumstance, Medicare will not reimburse for follow-up care. The clinical social worker may request the patient to sign a private contract as a condition for further treatment. If the patient does not sign a private contract with the clinical social worker and no longer requires emergency care, the clinical social worker would then refer the patient to a Medicare provider who would assume care of the patient and bill Medicare for continuing care. A clinical social worker who decides to opt-out of Medicare should do so properly and remain in compliance with the opt-out procedures. Private contracts are null and void when compliance is not met and the clinical social worker will be required to refund any amounts collected in excess of Medicare payment limits. NASW has received many complaints from clinical social workers who opted-out of Medicare but the patient billed Medicare for their psychotherapy services. The

3 clinical social workers were held liable by Medicare for repayment of the funds beyond Medicare limits because they did not have a private contract. In summary, remember the following when opting-out of Medicare: If you are not a Medicare provider, you can opt-out any time. If you are a Medicare provider, you must opt-out 30 days prior to the beginning of the Medicare quarters, January 1, April 1, July 1, and October 1. If you have not opt-out, you can see the Medicare patient, develop a private contract, and file an affidavit within 10 days of seeing patient. If you have not opt-out, you can see a Medicare patient for only emergency services and bill Medicare for emergency services as long as they are new to your practice. A private contract must be prepared and signed by both the patient and you and maintained in your files and available to Medicare upon request. An affidavit must be completed and mailed to your MAC. Upon approval, a letter will be mailed to you verifying you have opt-out of Medicare with the beginning and expiration dates. This opt-out letter may be required for payment by a secondary payer if you decide to bill them. Clinical social workers should use sample opt-out forms provided by their MACs. In the absence of sample opt-out forms, NASW has also prepared for its members sample opt-out forms for a private contract and an affidavit which are attached to this document. A list of MACs and their contact information is available at the following link: Intersocietal.org/iac/reimbursement/policies/ AB%20Medicare%20Administrative%20 Contractors%20(Updated% ).pdf. Opt-Out Procedures for Other Insurance Companies Some NASW members stopped accepting patients from insurance companies without any notification, only to discover months later that they had broken their insurance contract by charging in-network patients a higher fee. In such situations, insurance companies request an overpayment from clinical social workers. Clinical social workers who would like to terminate their contract with an insurance company, must follow the terms of termination listed in their provider contract. The provider contracts may vary amongst insurance companies. For example, termination requirements may range anywhere from 30 to 90 days. Clinical social workers who may be unable to locate their contract, may contact provider relations of their insurance company to obtain a copy of their most recent contract. Medicare payment may be made for emergency psychotherapy services performed by an opt-out clinical social worker who has not signed a private contract with the Medicare beneficiary requiring the service. In this circumstance, Medicare will not reimburse for follow-up care. Chapter 15 of the Medicare Benefit Policy Manual provides additional information about opting-out of Medicare and is available online at: cms.gov/manuals/downloads/bp102c15.pdf.

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