Submitting Out of Network Claims to Medicare (Help Please)!

[PX1985]

Hi all,

I'm a psychologist that is out-of-network with Medicare. I have a patient with schizoaffective disorder/dementia, so I've been submitting claims to his insurance throughout our work together when he used to have a private insurance company (I use Simple Practice, so it was easy to submit claims to private insurance companies.)

However, it seems I am unable to submit out-of-network claims before credentialing/enrolling with medicare (not becoming an in-network provider, but providing them with documentation required for submitting out of network claims).

Can someone help me understand how to accomplish this, or how to submit OON claims to medicare?

Any help would be much-appreciated!

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[PsyDr]

pretty sure you still have to enroll with PECOS, and watch a video that can tell you how to be a "non-participating provider".

 

[PX1985]

pretty sure you still have to enroll with PECOS, and watch a video that can tell you how to be a "non-participating provider".

Hello! Thank you for the quick reply.

Perhaps there is something I'm missing, do you know where I can view a video about how to become a "non-participating provider?"

While completing the PECOS application it is forcing me to "accept assignment," which I don't want to do because this patient can comfortably afford my full fee. I don't mind registering my TIN/NPI with medicare, but I don't want to accept their rates.

Please let me know if you have any further guidance re: this, as I've been on the phone with them for a few hours today already.

 

[PsyDr]

You can’t take full fee and be a non participating provider. You are limited to like 10% more than CMS or something.

Non participating = you can send a bill to CMS for slightly higher than they allow, but not your full fee

Opt out- you send a letter every 2-3 years, and can charge cash. CMS is not involved.

It’s easier to opt out and have them be cash pay.

Iirc, you have to send a HCFA to CMS. Idk the rest. Pecos will have information.

 

[Therapist4Chnge]

*edit*

I forgot about non-participating v fully opting out. My comments below are for fully opting out.
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To see Medicare pts outside of the Medicare system (cash pay) for different rates than Medicare pays, you must Opt-Out out from Medicare. You are either all-in or all-out, so you can’t see therapy pts in-network and assessment cases out-of-network. If you contract w a hospital or facility, you likely won’t be able to opt out bc they’ll want to charge Medicare under your NPI.

It used to be a big hassle bc you’d have to your opt-out every year or two, but I think they automatically re-up you every two years.

Every Medicare patient opting out from using their benefits requires a contract outlining their choice. You must keep it on file in case CMS requires verification. Be careful bc you do not want to mess with them on billing issues, so be clear on the requirements you need to follow every step of the way.

 

[PX1985]

*edit*

I forgot about non-participating v fully opting out. My comments below are for fully opting out.
—-

To see Medicare pts outside of the Medicare system (cash pay) for different rates than Medicare pays, you must Opt-Out out from Medicare. You are either all-in or all-out, so you can’t see therapy pts in-network and assessment cases out-of-network. If you contract w a hospital or facility, you likely won’t be able to opt out bc they’ll want to charge Medicare under your NPI.

It used to be a big hassle bc you’d have to your opt-out every year or two, but I think they automatically re-up you every two years.

Every Medicare patient opting out from using their benefits requires a contract outlining their choice. You must keep it on file in case CMS requires verification. Be careful bc you do not want to mess with them on billing issues, so be clear on the requirements you need to follow every step of the way.

Thank you for clarifying--Is there some resource that consolidates all these guidelines? The ones posted by CMS/Medicare are often unwieldy and I'm afraid (it seems rightfully so) to make any mistakes regarding this. I think I opted-out of Medicare previously, so should still be covered but would love to double check!

 

[PsyDr]

Thank you for clarifying--Is there some resource that consolidates all these guidelines? The ones posted by CMS/Medicare are often unwieldy and I'm afraid (it seems rightfully so) to make any mistakes regarding this. I think I opted-out of Medicare previously, so should still be covered but would love to double check!

1) If you "opted out", you are not covered.

2) To opt out"- you send a very specifically worded letter to CMS. You used ot have to do this every 2-3 years. Maybe you don't anymore.

3) To be a participating provider- you sign up via PECOS, and submit bills to CMS. It used to be the case that you had to print up HCFA-1500 forms

4) To be a non-participating provider- IDK. PECOS likely has information on this. MY guess is that you are just sending in a physical 1500. CMS caps what you can charge to something like 95% of their usual fees, or 10% extra or something. You will NOT get your full fee.

5) If you opted out, you might be able to send a HCFA-1500 as a non-participating provider. I'm guessing that CMS wants you to fill something in on PECOS for taxes (e.g., your EIN/SSN). And your PTAN. But you would have to see what the limits are in #4.

6) You can always look up your Medicare regional office, and give them a call. They are extremely helpful. But you will need to know if you are a "participating provider" (and know your PTAN), or if you have opted out. They speak a certain lingo, and you can't say, "I don't know if I opted out".

 

[PX1985]

1) If you "opted out", you are not covered.

2) To opt out"- you send a very specifically worded letter to CMS. You used ot have to do this every 2-3 years. Maybe you don't anymore.

3) To be a participating provider- you sign up via PECOS, and submit bills to CMS. It used to be the case that you had to print up HCFA-1500 forms

4) To be a non-participating provider- IDK. PECOS likely has information on this. MY guess is that you are just sending in a physical 1500. CMS caps what you can charge to something like 95% of their usual fees, or 10% extra or something. You will NOT get your full fee.

5) If you opted out, you might be able to send a HCFA-1500 as a non-participating provider. I'm guessing that CMS wants you to fill something in on PECOS for taxes (e.g., your EIN/SSN). And your PTAN. But you would have to see what the limits are in #4.

6) You can always look up your Medicare regional office, and give them a call. They are extremely helpful. But you will need to know if you are a "participating provider" (and know your PTAN), or if you have opted out. They speak a certain lingo, and you can't say, "I don't know if I opted out".

Wonderful, thank you.

I've been looking into it based on this info. It seems the opt-out status now auto-renews every two years unless you intervene. I've also learned that providers who have "opted-out" are advised to help their patients submit reimbursement forms, rather than submit CMS-1500 forms as a non-participating provider.