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Working With Medicare: The Basics
MEDICARE is federally run government healthcare for older Americans. MEDICAID is a state-run healthcare system for low-income individuals. Most MEDICARE patients are those over 65 years old or on dialysis but can also include people on disability (don’t forget about that one).
There are 3 main parts of Medicare: Part A (traditional hospital coverage), Part B (traditional out-patient coverage, Part C (private Medicare advanced plans run by private insurance companies like BCBS or Humana), and Part D (the drug benefit portion). If you establish a relationship with a Medicare beneficiary, you MUST bill Medicare, unless you are opted out. Most DPCs will opt out of Medicare before seeing Medicare patients. This is a tough decision for startup practices who may rely on moonlighting opportunities for income as their practice builds. There are some who decide to do DPC and only bill Medicare. Credentialing your practice with Medicare requires a separate practice NPI and the steps to bill Medicare are outside the scope of this article. Most opted-in practices who bill Medicare will only see patients with traditional part B as you may have to credential with each private insurance company to bill those with Part C Medicare Advantage.
You should also realize that your opt-out is effective for 2 years and will automatically renew every 2 years unless you apply to be reinstated. You have a 90 day window to change your mind, otherwise, assume you are opted-out for 2 years because opting back in within the 2 years is extremely difficult and rarely successful.
Those who opt-out of Medicare (internal link) are still in the Medicare system and retain a PECOS (Patient Enrollment Chain and Ownership System) number which allows you as a physician to order medications, imagining and referrals without any issues from Medicare. Opting out of Medicare does not change your PECOS status at all and nothing changes for your Medicare patients except they pay you directly. You do have to have Medicare patients sign a Medicare agreement with you (see example here) as well as an advanced beneficiary notice (ABN).
If you have been credentialed with Medicare as a private entity, you will likely only be able to opt-out once per quarter (Jan 1, April 1, July 1, and Oct 1) so you must plan accordingly. If you miss the deadline, you are stuck until the next quarter and you cannot accept payment from Medicare patients. In some areas, if you have only been credentialed as part of a larger organization, this limitation does not apply to you. And the opt-out process does have some regional variation, so speak with an attorney or DPC mentor near you to help you determine whether these deadlines are likely to apply to you, and how to opt-out in your region.
MEDICAID rules vary by state and the ability to contract with Medicaid patients will depend on your individual state’s laws..Dr. Phil Eskew’s DPC Frontier has the go-to resource for legal issues on working with Medicaid and Medicare.
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Working With Medicare: The Basics
MEDICARE is federally run government healthcare for older Americans. MEDICAID is a state-run healthcare system for low-income individuals. Most MEDICARE patients are those over 65 years old or on dialysis but can also include people on disability (don’t forget about that one).
There are 3 main parts of Medicare: Part A (traditional hospital coverage), Part B (traditional out-patient coverage, Part C (private Medicare advanced plans run by private insurance companies like BCBS or Humana), and Part D (the drug benefit portion). If you establish a relationship with a Medicare beneficiary, you MUST bill Medicare, unless you are opted out. Most DPCs will opt out of Medicare before seeing Medicare patients. This is a tough decision for startup practices who may rely on moonlighting opportunities for income as their practice builds. There are some who decide to do DPC and only bill Medicare. Credentialing your practice with Medicare requires a separate practice NPI and the steps to bill Medicare are outside the scope of this article. Most opted-in practices who bill Medicare will only see patients with traditional part B as you may have to credential with each private insurance company to bill those with Part C Medicare Advantage.
You should also realize that your opt-out is effective for 2 years and will automatically renew every 2 years unless you apply to be reinstated. You have a 90 day window to change your mind, otherwise, assume you are opted-out for 2 years because opting back in within the 2 years is extremely difficult and rarely successful.
Those who opt-out of Medicare (internal link) are still in the Medicare system and retain a PECOS (Patient Enrollment Chain and Ownership System) number which allows you as a physician to order medications, imagining and referrals without any issues from Medicare. Opting out of Medicare does not change your PECOS status at all and nothing changes for your Medicare patients except they pay you directly. You do have to have Medicare patients sign a Medicare agreement with you (see example here) as well as an advanced beneficiary notice (ABN).
If you have been credentialed with Medicare as a private entity, you will likely only be able to opt-out once per quarter (Jan 1, April 1, July 1, and Oct 1) so you must plan accordingly. If you miss the deadline, you are stuck until the next quarter and you cannot accept payment from Medicare patients. In some areas, if you have only been credentialed as part of a larger organization, this limitation does not apply to you. And the opt-out process does have some regional variation, so speak with an attorney or DPC mentor near you to help you determine whether these deadlines are likely to apply to you, and how to opt-out in your region.
MEDICAID rules vary by state and the ability to contract with Medicaid patients will depend on your individual state’s laws..Dr. Phil Eskew’s DPC Frontier has the go-to resource for legal issues on working with Medicaid and Medicare.