Why it’s Important to Screen and Monitor Against the Medicare Opt-Out List

HEALTH CARE PROVIDERS CAN OPT-OUT OF MEDICARE

When credentialing providers, it is important to check and monitor against the list of those providers who have opted out of Medicare. Health care providers can decide independently to opt-out of participation in Medicare which covers all Medicare programs including original fee-for-service Medicare, Medicare Managed Care Plans, Medicare+Choice Plan, and Medicare Advantage Plan. An opt-out covers all services, items, and locations.

AVOIDING FINES AND PENALTIES FOR SEEKING REIMBURSEMENT ON OPTED OUT PROVIDERS

Fines per incident, civil monetary penalties, plus restitution can be levied by the Federal Government if services provided by an opted-out provider is submitted to Medicare for reimbursement. The Centers for Medicare and Medicaid (CMS) publishes a list of providers who have opted out of Medicare according to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 that requires in Section 106(a)(2) that the list of all providers with approved affidavits of opt out be available to the public.

PROCESS FOR OPTING OUT

Opting out requires the provider to submit an Opt Out Affidavit with Medicare and disclose this information to all carriers with jurisdiction over claims the provider would otherwise file with Medicare. If approved, the opt-out period lasts for two years. Once opted-out, neither the provider nor the beneficiary can file for reimbursement from Medicare and its programs. Beneficiaries must pay directly for health care services under a Private Contract with the provider.

Providers who are opted-out will automatically be renewed for the next two-year period unless Medicare receives a cancellation request 30 days prior to the expiration date. With the automatic renewal of opt-out, combined with a typical overload of administrative requirements, a provider or a health care organization may not be aware of a provider’s opt-out status.

REASONS FOR OPTING OUT

Reasons for opting out can be that a provider no longer wants to serve Medicare beneficiaries, that the provider no longer wants to follow the fee-for-service charges mandated by Medicare and practices medicine on a cash basis, or that a type of specialty service is not covered by Medicare. There is a growing trend of providers opting-out who feel fatigued from having to comply with the more than 11,000 regulations governing medical practice. Other reasons include wanting to become eligible to order, certify and prescribe, or prescribe Part D Prescriptions to Medicare beneficiaries.

Opting out is also used as a strategy to conceal and avoid an impending exclusion, sanction, debarment, or disciplinary action and dodge being listed on the Health and Human Services (HHS) Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE). The regulatory compliance checkpoints built into the Medicare programs that are designed to protect patients and mitigate fraud, waste, and abuse are no longer enforceable if the provider has opted out. Other efforts to conceal adverse actions include changing license type and state of practice.

NOT ALL PROVIDERS HAVE THE ABILITY TO OPT-OUT

Provider types not eligible to opt-out include:

• Anesthesiologist Assistants
• Chiropractors
• Occupational Therapists
• Physical Therapists
• Speech Language Pathologists

Provider types who are eligible to opt-out include:

• Certified Registered Nurse Anesthetists
• Clinical Nurse Midwives
• Clinical Nurse Specialists
• Clinical Psychologists
• Clinical Social Workers
• Doctors of Dental Surgery or Dental Medicine
• Doctors of Medicine
• Doctors of Optometry
• Doctors of Osteopathy
• Doctors of Podiatric Medicine
• Nurse Practitioners
• Physician Assistants
• Registered Dieticians and Nutrition Professionals

MATCH OR NO MATCH?

The searchable Affidavit opt-out list published on the CMS website is updated monthly and includes First and Last Name, NPI Number, Specialty, Opt-out Effective Date, Opt-out End Date, Address, and Eligibility to Order and Refer.

With only this information, true identity matching can be tricky in the event that a provider has changed his/her name, is using an alias, has multiple NPI numbers, has changed provider type, or has changed their address. The Affidavit application contains the provider’s social security number, date of birth, and license number along with additional contact information that could be used to positively match an opt-out record to an individual with utmost certainty. However, without that protected information, there is room for error.

SIGNIFICANT NUMBERS OF OPT-OUT

There are 25,303 providers on the opt-out list with requests slowing down from a peak number of 7,400 in 2016. The opt-out trend began in 2010 with 130 requests, that jumped to 1,600 in 2013, to 3,500 in 2015, 7,400 in 2016, with a slowdown to 3,732 in 2017 likely due to the automatic opt-out renewal feature.

TECHNOLOGY AND AUTOMATION SIMPLIFY REGULATORY COMPLIANCE

Verisys includes the opt-out list as one of the thousands of primary sources in its SaaS platform CheckMedic®. Within CheckMedic’s 320 million-record aggregated database, Verisys uses sophisticated algorithms with matching logic to render a 99.9% match, 99.9% of the time.

To reach and sustain regulatory compliance in order to participate in federal entitlement programs or to implement best practices in your compliance program requires both automation and data intelligence to remove any uncertainty regarding a provider’s status. Verisys has 25 years under its belt collecting data records, aggregating against sophisticated algorithms, verifying primary sources, and building a cloud-based platform for ease of access as well as comprehensive data views.

Learn more about how Verisys can assist your HCOs in meeting all government and regulatory standards.

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