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pting out of Medicare begins with a philo-sophic choice. Believers in a free market will

nd government regulation and bureaucracy sti-ing, while others may find it tolerable. You mustsk yourself whether participation in the program isonsistent with your values. You may be able toerve your patients better—even Medicare-eligibleatients—if you opt out.Opting out of Medicare also involves an economic

hoice. It will result in a loss of income—possiblyemporary, possibly permanent. Your practice mayrecover” (fill in with better payers), or you may seeewer patients. It is important to consider that theost work and lost income are not proportional.

edicare pays less and costs more per patient onverage. More time off with less income may be aesirable choice for you (“they can’t tax your timeff”).

A Black Box Analysis of Insurer X

Your worst payorHas the oldest, sickest patientsHas the most demanding patientsHas a false appeals processOverrules all your medical decisionsImposes thousands of stupid rulesHas literally twice the billing workHas the maximum bureaucracyCan confiscate your life savingsCan put you in jail

So why would you take this insurance?

ractical Tips for Optingut

found that Association of American Physicians andurgeons is your best source for information onpting out. The website, www.aapsonline.org, offersample documents and a forum to share experi-nces. AAPS can put you in contact with other doc-

ors who have opted out. v

090-3019/04/$–see front matteroi:10.1016/j.surneu.2003.12.005

Be aware that the Center for Medicare and Med-caid Services (CMS) is neither a knowledgeable noreliable source of information about opting out. Weeceived a new wrong answer each time we spokeith a new CMS bureaucrat. Remember that CMS isot responsible for its own advice.You must do your own research. It is well worth

t to hire an attorney experienced in health-careaw. AAPS members can receive individualized as-istance from the Limited Legal Consultationervice.Be sure to document all contacts with CMS. Al-ays send everything certified mail to CMS.Medicare provides quarterly “exit points”; youill need to plan ahead.When you have made the decision to opt out,

end your affidavit to CMS and all Medicare carriershat you have previously billed.

ducating Patients andhysicians

e sure that all prospective patients and your col-eagues understand that:

. You are “out of network” for Medicare.

. Medicare should pay for tests ordered by anopted- out doctor (experience has varied), andPart A coverage is not affected.

. If patients want to use their Medicare Part Bbenefits for physician fees, they must see a Medi-care doctor.

Send your referring physicians a letter explainingour position and motivation for leaving Medicare.our closest colleagues deserve a personal phoneall.Also write to your current Medicare patients to

xplain their options for future care. Both patientsnd physicians must understand that your servicesre still available under private contract (see “ca-

eats” below).

© 2004 Elsevier Inc. All rights reserved.360 Park Avenue South, New York, NY 10010–1710

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181Editorial Surg Neurol2004;62:180–182

reparing Your Staffou need to have written, rehearsed “canned” ex-lanations, such as:

“Dr. Smith terminated his contract with Medicare.”

“Dr. Smith is “out of network” for Medicare.

“Secondary insurances, in our experience, maynot pick up the tab. If a patient files a Medicareclaim—which will be rejected because the doctoropted out—the secondary insurer may pay.”

Support your staff: be prepared to take the heatersonally.Train your staff to determine whether a patient isMedicare beneficiary: that includes anyone over

he age of 65 who has accepted Part B; anyone onedicare disability; “dual eligible” persons on Med-

caid; and former non-Medicare patients whourned 65. Such patients should not be scheduled.ou may make an exception for Medicare-eligibleatients who clearly desire to contract privately.

efore You Opt Outou should decrease your Medicare Accounts Re-eivable and percentage of Medicare patients prioro opting out. Expect CMS to bury your existingMS A/R the minute you opt out. If your practiceas decreased its dependence on Medicare, theconomic risk will be lessened, and a smaller Ki-rkegaardian “leap of faith” will be required.If you are unsure whether or not to proceed with

pting out, float some test balloons. Stop Medicaidrst. Stop seeing new Medicare patients. Limit theumber of Medicare patients per week. Check forny sizable ripple effect on the rest of your practicend for significant economic impact. Note any in-reased efficiencies.

hat Actually Happensfter You Opt Out?

here will be a Stun Factor. Jaws drop. People ask,You did what? I didn’t know you could do that.”

Initially, you will notice that you have more timeff. Your office staff will feel unchained. It is impos-ible to overestimate the lift you and your staff willet when you finally dump the biggest albatross ofll time. All that extra energy and resources thatsed to spiral down the CMS drain can now beedirected into the remaining practice. You can pro-ide better service. Your employees will be happiermployees. Your Accounts Receivable will improve.

verything will be more efficient, especially the t

back office.” Every practice process will benefit,ither directly or indirectly.You may be surprised by the support from pa-

ients who are unhappy with Medicare and fromhysicians who approve of your moral stance anddmire your courage. They will say, “I wish I couldo that.”Best of all, CMS will no longer own you. You have

scaped tremendous risks that can be eliminated ino other way. You are free to ignore future edictsnd hassles from Big Brother. Imagine getting theurrent CMS bulletin full of rules and being able tognore it and throw it away—priceless!

aveatsENEWALSou must renew your opt-out status every 2 years.ailure to do this has serious repercussions. Puteminders on every calendar. Schedule remindersnto your practice management software. Assignour staff, partners, lawyer, and accountant to re-ind you. Did you opt out in an even or odd year?enew your opt out every even or odd year there-fter. Send in your opt-out renewal well in advancef the deadline.Keep all your opt-out documents on your word

rocessor so that you can easily renew by changinghe dates. Do check the AAPS web site for anyhanges to the procedure.

RIVATE CONTRACTS WITHEDICARE-ELIGIBLE PATIENTS

ou may see Medicare patients in the office afterpting out, but only if they sign a “private contract”cknowledging that (1) you have opted out; (2)edicare will not pay for your services; and (3) the

atient is responsible for your bill. Additional jar-on is also needed (see the AAPS Web site), and youust keep the “private contracts” on file, in case the

arrier demands a copy. Do not provide paperwork,uch as CPT codes, that a family member could useo file a Medicare claim without your knowledge.

RGENT/EMERGENT MEDICAREATIENTS.ou must treat such patients and submit the bill toedicare with the “GJ” modifier. Don’t expect to getaid, as Medicare will deem your services “Non-rgent.” Or there may be a marked delay in pay-ent with numerous follow-up calls to clueless car-

ier staff. In any event, once the patient is “stable,”ou must offer a choice: (1) Enter into a privateontract with you outside Medicare; or (2) Transfer

o a Medicare physician.

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182 Surg Neurol Editorial2004;62:180–182

O NOT BILL MEDICARECCIDENTALLYisable the billing software for Medicare Billing,nd delete the Medicare billing address. Fill it inanually each time you bill for a GJ emergency.

VOID “SURPRISE” MEDICAREATIENTSon’t schedule patients in the categories listed above.

ncorporate a Disclaimer into your “Consent for Treat-ent Form”: “I am not a Medicare Beneficiary.”

inal Thoughtseigh the risks of not opting out. Remember that

eminds me of the old Soviet Union: Stalin randomlyicked names out of the phone book and executedhose persons. Random terror is a very effectiveeans of controlling the masses. The best defense:

ake your name out of the phone book.

Timothy C. Kriss, M.D.Versailles, Kentucky

eprints available from:Association of American Physicians

and Surgeons1601 N. Tucson Blvd. Suite 9Tucson, AZ 85617(800) 635-1196; www.aapsonline.org

MS can interpret billing errors as criminal acts. It Pamphlet No. 1094, December, 2003