CMS Medicare Opt-Outs | FAQ

Learn why placing your practice on the CMS Medicare Opt-Out list prevents you from working with Grow Therapy.

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Providers sometimes put themselves on the CMS Medicare Opt Out list because they believe they must do this to avoid seeing Medicare clients. Instead, they enter private contracts with patients and charge them directly for services. By doing so, these providers are not subject to Medicare's rules and regulations, including fee schedules and coverage limitations. Not only is this action unneeded to avoid seeing Medicare clients, but it also affects their potential partnership with Grow.

TLDR: Grow cannot work with any provider on the government-regulated Medicare Opt Out list, as seen in Section 1C of our Policies and Procedures.

To remove yourself from the opt-out list, follow the instructions listed under Cancelling an Opt-Out Status on the CMS enrollment website. Once you no longer appear on the opt-out list, Grow can reprocess your applications.

What does it mean to opt out of Medicare?

Physicians and practitioners who do not wish to enroll in the Medicare program may "opt-out" of it. This means neither the physician nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician out-of-pocket, and Medicare reimburses neither party. A private contract is signed between the physician and the beneficiary, stating that neither one can receive payment from Medicare for the services performed.

Before opting out of Medicare, you should consider the following impacts:

  • Opt-out periods last for two years and cannot be terminated early unless you are opting out for the very first time and you terminate your opt-out no later than 90 days after the effective date of your first opt-out period.

  • Physicians and practitioners may NOT opt out if they intend to be Medicare Advantage (Part C) providers or furnish services covered by traditional Medicare fee-for-service (Part B).

Why can't Grow work with providers on the opt-out list?

Because the insurance companies we partner with often work with Medicare for their MCO products, they don't allow providers to be on the Medicare Opt-Out list. Therefore, we can't allow it either. If they're on the list, we can't guarantee that they will be paid for their services even if it's not a Medicare client. If providers are curious about why this is:

  • Network Inclusion: Insurance companies aim to build a robust network of healthcare providers to offer their clients a wide range of choices for medical care. Providers on the Medicare Opt-Out list might limit the network's breadth and accessibility, potentially affecting the insurer's ability to offer comprehensive coverage.

  • Patient Access: Insurers want to ensure their clients access a diverse pool of healthcare providers. Providers on the Medicare Opt-Out list might restrict access for patients who prefer or rely on Medicare coverage, impacting the insurer's ability to serve a broader population.

  • Coordination of Care: Insurance companies often work to coordinate care for their beneficiaries across different healthcare services. Providers on the Opt-Out list might not adhere to Medicare regulations, making it challenging for insurers to ensure seamless coordination of care for their clients who may also be Medicare beneficiaries.

  • Consistency in Billing and Reimbursement: Insurers have established billing and reimbursement processes. Providers on the Opt-Out list have different billing practices, potentially complicating the insurer's administrative procedures and reimbursement mechanisms.

What happens if I'm on the opt-out list?

Grow will notify all providers on the CMS Medicare Opt-Out List that they will be terminated within 30 days of detection. If a provider wishes to remove themselves from the CMS Medicare Opt-Out List, they must submit proof of the cancellation request prior to the termination date.

How do I remove myself from the opt-out list?

To remove yourself from the opt-out list, follow the instructions listed under Cancelling an Opt-Out Status on the CMS enrollment website. Once you no longer appear on the opt-out list, Grow can reprocess your applications.

Can I work with Grow while not accepting Medicare?

Yes. All providers can adjust the referral settings in their provider portal to choose which insurance they accept. Additionally, Medicare enrollment with Grow is optional. Please note that some states may require certain license types to enroll with Medicare to bill for clients covered by Medicaid.

If providers would like to work with Grow but not accept Medicare, they can either turn off Medicare referrals in their provider portal or forego enrolling with Medicare altogether. All they need to do is indicate their preference when asked about enrolling with Medicare on the credentialing form.

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