To opt out of Medicare, a physician must submit an opt-out affidavit to the Medicare administrative contractor for his or her region. The contractor must receive the affidavit at least 30 days be- fore the start of the calendar quarter in which the opt-out decision is to become effective.
Ms. Davis says there sometimes is confusion between opting out of Medi- care and becoming a nonparticipating — or “nonpar” — physician.
A nonparticipating physician can still bill Medicare and elect to accept assign- ment on a claim-by-claim basis. A non- participating physician normally will receive 5 percent less than a participat- ing physician for the same service, even if assignment is accepted on the claim. And, nonparticipating physicians who collect from or balance bill the patient cannot collect more than the limiting charge, which is just 9.25 percent more than the Medicare fee for participating physicians. Federal officials say there is not enough data to accurately determine how many physicians across the coun-
try have opted out of Medicare, but the number appears to be growing. In April 2011, the U.S. Department of Health and Human Services Office of the Inspector General (OIG) set out to study the impact of physicians leav- ing Medicare, including the character- istics and number of physicians opting out and their reasons for doing so. OIG concluded, however, that neither the U.S. Centers for Medicare & Medicaid Services (CMS) nor its Medicare admin- istrative contractors across the country were maintaining sufficient data to con- duct the study.
Still, OIG concluded the number of doctors opting out of the program was growing. “Based on the limited data that we received, the number of opted-out physicians appears to have increased each year from 2006 to 2010,” OIG stat- ed in a report issued in January. TrailBlazer Health Enterprises, the
Medicare contractor for Texas, appears to be one of the few contractors who keep data on opted-out physicians. A review of a list of opted-out doctors on TrailBlazer’s website found more than
400 in Texas alone. The list also includ- ed dozens of opted-out psychologists, physician assistants, dentists, and other health care professionals.
While those numbers may be small, it
is likely they will continue to increase. Preliminary results from a new TMA sur- vey found that 44 percent of Texas physi- cians were considering opting out of the Medicare program. Getting out is not the only way phy-
sicians reduce their Medicare expo- sure. According to the TMA survey, the number of physicians accepting all new Medicare patients dropped from 66 per- cent in 2010 to 58 percent in 2012 (see
Texas physicians who will accept all new Medicare patients
100% 80% 60% 40% 20% 0
28 TEXAS MEDICINE July 2012 78+74+67+62+64+66+58 2000 2002 2004 2006 2008 2010 2012
“Texas Physicians Who Will Accept All New Medicare Patients”). That’s part of a trend that’s seen the number decline steadily from 78 percent in 2000. Mean- while, the number of physicians who limit the number of new Medicare pa- tients they accept and the number who decline all new Medicare patients each rose by 4 percent in the past year. Donna Kinney, CPA, TMA’s director of health care research and data, over- saw that survey and called the 8-percent decline in physicians accepting all new Medicare patients “a stunning drop.” TMA Immediate Past President C. Bruce Malone, MD, of Austin, says un- certainty over Medicare physician pay- ment rates because of the Sustainable Growth Rate (SGR) formula drives many physicians to contemplate dropping out of Medicare.
“It all boils down to economic deci- sions doctors make to keep their practic- es viable,” Dr. Malone said. “The charade of Congress ‘fixing’ the SGR problem has gone on long enough. I think some doc- tors have just given up and may resort to a cash-only primary care practice.” And it’s not just payment issues driv- ing physicians out of the program. Dr. Carpenter opted out in October 2011 because Medicare’s regulatory burden was getting to be too much. It includes new requirements for adopting electronic medical records, e-prescribing, and providing bank account information so Medicare can pay them electronically. “Every time you turn around, some- one has a new rule or a new regulation or a new audit or a new something,”
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