Medicare - Opting In or OutMedicare Clarification – Required LCSW Opt In/Opt Out -- December 2010Medicare is a complex system which has caused confusion for many LCSWs. Most LCSWs know that we must accept referrals if we sign up as a Medicare provider. What has been less clear is that LCSWs must “opt out” of the Medicare system, or they will be considered available to receive Medicare patients and be violating Federal law by not accepting Medicare patients. LCSWs are “eligible” to become Medicare providers but are in limbo until they “opt-in” by completing Medicare enrollment forms. Information on how to opt-in or opt-out follows below. "Opting-Out” of Being a Medicare ProviderOnce an LCSW becomes a Medicare provider, he or she may opt out of Medicare and privately contract with beneficiaries to provide services that would be covered by Medicare. The opt-out period is generally for two years. Opt-outs may be renewed for subsequent two-year periods. The provider must opt out of Medicare for ALL beneficiaries and services with the exception of emergency or urgent care situations. The private contract between the LCSW and the Medicare enrollee must state that neither party will seek reimbursement from the Medicare program. The clinician is then free to charge the Medicare enrollee his/her customary fee. Additionally, any Medicare-enrolled LCSW who has not submitted a Medicare claim for 12 consecutive calendar months will be disenrolled from the Medicare program. LCSWs can reapply after being dropped from the Medicare provider list to become a provider again, if they so choose (Medicare Reimbursement for LCSWs: Past, Present, and Future, access, 10/06). LCSWs are used to thinking about how to get onto insurance panels, not about how to stay off them. Here are some of the reasons that LCSWs may want to opt out of being a Medicare provider:
{Article written by Laura Groshong, LICSW, CSWA Director, Government Relations} ©CSWA2010 |
Additional Medicare ResourcesWhile it is true that the application process is lengthy and complicated, and the opt-out process also takes some work, the Social Security Law as of 1990 states that all LCSWs must “opt-out” of Medicare if they choose not to “opt-in”, i.e., become an official Medicare provider. This law is not one with which most LCSWs are familiar. Title XVIII, Section 1848(g)(4) of the Social Security Act requires physicians, suppliers, and other persons to submit claims for services rendered to Medicare beneficiaries on and after September 1, 1990. The URL is http://www.ssa.gov/OP_Home/ssact/title18/1848.htm. Ignoring the Medicare system as an LCSW, psychologist, or psychiatrist is not an option under the law, though many clinicians have done so. The whole concept of having to “opt-out” of an insurance panel is alien to the mindset of trying to get on them; many LCSWs have been shut out of private insurance panels for which they would like to be providers. Nonetheless, it is important to make an informed decision about opting in or opting out of Medicare or ignoring the system.
Though Medicare rates for LCSWs vary by region, they generally fall between $60-80 for 90806 provided by an LCSW. To find out more, go to Medicare Fees: http://www.cms.gov/apps/physician-fee-schedule/overview.aspx - scroll down and click on “Start Search”. Then click on “Pricing Information” or “Geographical Practice Cost Index” (these can only be done separately) and the CPT codes (90801 - 90806). Then click on “Specific Locality” and “Global”. Your area rates should come up. Remember that the payment schedule for LCSWs are 75% of what physicians are paid and correct accordingly. You can find more information at http://www.cms.gov/apps/physician-fee-schedule/help/Medicare-Physician-Fee-Schedule-Search-Help.pdf.
We urge all LCSWs to follow the laws regarding Medicare and opt-in to the Medicare system or opt out. The URL for opting in to the Medicare system is http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp, which will take you to the PECOS Medicare enrollment page for LCSWs, Form 855i. There are several fact sheets which are worth reviewing. As LCSWs, we are “non-physicians” in the Medicare system, and those are the documents that should be used. Information about opting out of Medicare can be found at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. There is no form supplied by CMS, just instructions on what must be included in a letter that will allow you to opt out. |