Navigating Medicare Opt-Outs in Group Practices: A Comprehensive Guide

 In the ever-evolving landscape of healthcare administration, understanding the intricacies and implications of Medicare opt-outs within group practices is essential. This guide aims to address common questions and concerns raised by practitioners and group practice leadership, shedding light on how opting out is done on an individual basis and what the impacts of individual opt-outs are in a group practice context.

Understanding Medicare Opt-Outs

Medicare opt-outs are a crucial decision for healthcare practitioners, especially those operating within group practices.

Opting out means that practitioners choose not to and cannot accept Medicare reimbursement for services provided to Medicare beneficiaries. Instead, they contract directly with clients, agreeing not to bill Medicare for any services rendered by the non Medicare enrolled provider. 

Individual Basis Opt-Outs:

One of the fundamental aspects to grasp in the group practice context is that Medicare opt-outs occur *only* on an individual basis, whereas Medicare enrollment occurs both on an individual basis *and* under the group practice on an organizational basis.

Each practitioner within a group practice must take action regarding opting out, or enrolling, as a Medicare provider.

If a group practice as an organization decides not to enroll as a Medicare provider — which also means that if an individual provider within the group *is* a Medicare enrolled provider that they cannot provide care to any Medicare beneficiaries under the group practice —  each practitioner within that group must take action individually to submit an opt-out affidavit to Medicare, or to enroll. (More on whether or not an individual provider can be enrolled but see clients at a group practice that is not enrolled, and how that works, below.)

Implications for Group Practices:

The decision for a group practice to not enroll as a Medicare provider [done under the group’s NPI 2 (organizational) number] — which is what, in effect, constitutes opting-out as a group practice —  can have significant implications.

It’s essential for group practice owners and leaders to understand that not enrolling means foregoing Medicare reimbursement entirely. This can impact the practice’s revenue stream, referral sources, client population, and overall financial stability.

It is also necessary to understand that not enrolling can have consequences for the individual providers within your practice — which in turn can impact clinician hiring and retention — as well as for the logistics and processes for how the practice manages serving clients who may be Medicare beneficiaries.

If a group practice requires that their clinical staff individually opt-out of Medicare, that has the potential to limit the hiring pool because of the immediate and medium-term (2 year) effect of opting out and how that may impact the clinician presently, and limit their future options.

If a group practice serves any clients that are potentially Medicare beneficiaries, it is necessary to identify and verify the Medicare status for each client/prospective client. If the practice has not enrolled under their NPI 2 as a Medicare provider, then a Medicare Opt-Out Contract must be executed with each client that is a Medicare benificiary.

If a group practice has a clinician that is an enrolled Medicare provider, but the group practice is not enrolled, then that clinician cannot see clients at the group practice that are Medicare beneficiaries; a Medicare Opt-Out Contract *cannot* be executed for services provided by a Medicare enrolled provider to a Medicare beneficiary.  In such an instance, Medicare beneficiary clients could only see clinicians at the group practice who are individually opted out of Medicare (and the Medicare Opt-Out Contract executed with those Medicare beneficiary clients.) This can, of course, be managed but it is imperative to have a diligent and accurate process for doing so in order to avoid the potentially serious consequences that can arise if there were to be a failure in the effective management of this situation.

Navigating Dual Affiliations:

One common concern among practitioners in group practices is how opting out of being a Medicare provider may intersect, and potentially conflict, with other affiliations and professional needs and wants — such as working in a hospital, community mental health, outpatient clinic, or maintaining a private practice.

It’s crucial to recognize that opting out is tied to the practitioner’s National Provider Identifier (NPI) 1 (individual) number. This means that if a practitioner opts out of Medicare, they are opted out of Medicare in any and every practice context/care delivery setting for the duration that they’re opted out. Opting out for the purpose of one practice context has the consequence of being opted out in every practice context.

If a practitioner were to opt-out for the purpose of one practice context, they may still be required to be enrolled as a Medicare provider in another, depending on their contractual obligations with the other employer and the client population they work with — e.g. in a hospital — which sets up a potential conflict and consequential choice.

If an individual provider opts-out of Medicare, they cannot enroll as a Medicare provider for 2 years. There is an initial 60 day grace period, the first time an individual opts-out, during which they can change their mind and decide to enroll. However, once that 60 days has elapsed — or if they are opting out for a second time — they are then restricted to being a non-Medicare provider in all practice and client care delivery settings for 2 years.

Furthermore, individual providers do not have the option to take no action — all Medicare eligible providers (those licensed in Medicare provider eligible professions) are required to either opt-out or to enroll. Group practices do not have to take action to effectively be opted-out of Medicare as an organization in terms of filing an opt-out with Medicare, but still must make an explicit decision about not enrolling and effectively being opted-out and then manage processes to appropriately provide care to Medicare beneficiaries without being in violation of federal Medicare laws.

Mitigating Compliance Risks:

Group practice owners must navigate the complex landscape of Medicare compliance to avoid potential pitfalls. Failure to properly manage Medicare opt-outs can result in penalties, fines, or even loss of enrollment privileges. It’s essential to develop robust processes for identifying practitioners opting out, ensuring accurate billing practices, and maintaining compliance with Medicare regulations.

Navigating Medicare opt-outs within group practices requires careful consideration and a thorough understanding of the implications involved. By grasping the individual basis of opt-outs, mitigating compliance risks, and addressing concerns regarding dual affiliations, practitioners and practice owners can make informed decisions that align with their goals and priorities. Ultimately, by staying informed and proactive, group practices can navigate Medicare opt-outs successfully while continuing to provide quality care to clients.