Medicare Opt-Out and Group Billing: The Practice Still Submits the Claim

A group practice billing Medicare for an opted-out physician’s own services cannot use reassignment to get around the opt-out. The group may still bill for its other eligible clinicians, and Medicare has specific emergency and urgent-care exceptions. If you know the physician stopped accepting Medicare payment but the practice kept submitting claims for that physician’s work, the service date, patient contract and actual bill tell the story.

What Medicare Opt-Out Changes

Medicare opt-out lets a physician arrange private payment with Medicare patients for services the program would otherwise cover. It follows the individual’s furnished services across locations. The physician cannot choose to opt out for selected patients or selected covered services while continuing ordinary Medicare billing for the rest.

The Centers for Medicare & Medicaid Services distinguishes opting out from being a nonparticipating Medicare physician, whose services can still qualify for Medicare payment. Opting out puts otherwise covered care under private contracts, subject to the emergency and urgent-care rules. A practice’s description of the physician as nonparticipating cannot replace the actual opt-out status. If Medicare exclusion also applies, its effective date takes precedence and its separate payment restrictions govern.

Can a Group Practice Bill Medicare for an Opted-Out Physician?

The group cannot bill Medicare or receive Medicare payment for the opted-out physician’s furnished services under an ordinary reassignment arrangement. The Medicare Benefit Policy Manual addresses this exact relationship: a physician remains in a group or continues assigning payment rights to an organization after opting out. The organization can still collect from the patient under the private contract if the physician has given it that right. Medicare’s money is the part that stops.

A healthcare group may employ or contract with clinicians and receive their reassigned payments, while a management services organization handles contracted administrative functions. The clinical work, the billing operation and the money can sit in different hands. We follow the service through those relationships because changing the recipient of payment does not change whose care Medicare is being asked to fund.

Does Opt-Out Apply to Medicare Advantage and Secondary-Payer Claims?

Medicare Advantage plans also face the opt-out payment restriction, including payments made indirectly for the physician’s covered services. The manual preserves the emergency and urgent-care exception for patients without a prior private contract. Medicare as a secondary payer is covered too: it makes no primary or secondary payment for services furnished under the private contract. Moving the bill to a plan or behind another insurer does not remove the physician’s opt-out from the payment question.

The Service Date Connects Opt-Out Status to the Claim

The effective opt-out period determines which services fall under the restriction. Medicare contractors maintain the physician’s identity, the effective date, renewal information and any cancellation or end date. What counts is the date the patient was seen, not the date the claim went out.

Opt-out affidavits filed on or after June 16, 2015 automatically renew every two years unless the physician cancels the renewal. The renewal and cancellation history shows whether that older affidavit still covered the visit being billed.

What Evidence Does a Whistleblower Need?

A whistleblower’s evidence connects the clinical record and submitted claim to the practice’s billing decisions. The schedule, treatment notes, signatures and supervision records identify who did the work and how it was furnished. The claim shows the practitioner and service represented to Medicare; the payment record shows what the practice received. The private contract and any emergency-care documentation complete that comparison.

For an enrolled clinician who furnished and reassigned a service, the Medicare reassignment rule provides access to the claims the reassignee submitted for that service. That makes the enrollment and reassignment relationship relevant when examining claims billed under your NPI.

A claim naming the physician as the ordering professional raises a different question from a claim for that physician’s own treatment. Medicare may pay another eligible provider for medically necessary services ordered by an opted-out physician who meets the ordering requirements. We distinguish who ordered the care from who furnished the service Medicare paid for.

The Journal of AHIMA’s 2017 article Busting Bad Medicine: A Call to Action Addressing Healthcare, Fraud, Waste, and Abuse describes comparing treatment dates, treatment details and clinical signatures with health care billing documentation. It also emphasizes witnesses who can explain what happened beyond the paperwork. In an opt-out inquiry, that is where the physician or billing employee can connect the care to the practice’s decision to send the bill.

Private Contracts Put Payment With the Patient

A Medicare private contract puts payment for the opted-out physician’s otherwise covered care with the patient. The manual requires a written agreement signed by both sides, provided before the service and tied to the current opt-out period. The physician retains it and makes it available to the agency on request. Those features connect the payment arrangement to the particular patient and visit.

An advance beneficiary notice addresses a different situation: the physician believes Medicare will not pay for a service. A private contract addresses care Medicare might otherwise cover, with the patient agreeing to pay outside Medicare. A group’s authority to collect that private payment leaves the Medicare billing restriction in place. A missing private contract raises its own payment questions, and we work through them with you.

Emergency and Urgent Care Have Their Own Billing Rules

Medicare permits payment for emergency or urgent care furnished by an opted-out physician when the patient has no prior private contract with that physician. The GJ modifier identifies the opt-out physician’s emergency or urgent services and the absence of a private contract. The manual bars entering a private contract while the patient needs emergency or urgent care.

A prior private contract within the current opt-out period changes the result: the manual directs denial of Medicare payment for the emergency or urgent services. The patient’s condition and contract therefore belong beside the claim’s modifier.

Ordinary follow-up care falls outside the emergency exception once the patient no longer needs emergency or urgent treatment. If a practice keeps marking ordinary follow-up visits as emergencies, the treatment record and the claim show the mismatch. Follow-up care that still requires emergency or urgent treatment can remain payable under the exception.

When the Group Received the Prohibited Payment

The manual expressly addresses the salaried physician or group member who does not personally submit bills. When a contractor identifies prohibited payment for that opted-out physician’s work, the manual directs recovery from the hospital, clinic or group practice after notification. We see the contradiction: the physician has opted out, but the practice still asks Medicare to pay for that physician’s work. When prohibited claims get paid, the practice makes the government pay for care that belongs outside ordinary Medicare billing.

We examine this part of physician practice fraud through the care, the claim and the decisions inside the business. An insider’s knowledge can connect what the practice knew about the physician’s status to the Medicare money it requested. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know Whose Work the Practice Billed

If you are the billing employee, practice manager or physician who saw an opted-out physician’s services go to Medicare, speak with our whistleblower experts about the group’s billing. We build your strongest physician billing fraud case around the care, the payment and the decisions you can explain, and bring in physician billing fraud whistleblower lawyers who understand group-practice claims. We stay with you from understanding the group’s billing decisions through the work of pursuing your case.