Medicare Opt Out Form?
AnsweredDoes anyone have a form/template for Medicare-eligible clients to complete to declare that they are opting to self-pay as opposed to using their Medicare benefits? I have completed the opt-out process with Medicare as a provider, but I am aware that I also need my clients to complete an additional form acknowledging that they are opting out of using Medicare benefits when they choose to work with me.
Thank you!
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Per the information that I have received, affidavits now auto-renew every 2 years (historically there was a need to re-apply periodically, but that was changed in 2015). https://med.noridianmedicare.com/web/jeb/enrollment/opt-out#private_contract
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Hi Corrie, I have recently done this. If you have already received confirmation from regional medicare contractor (MCO) that you are no longer a participating provider, you need to sign a private contract with the patient. Here is a link to Sample contract form. This needs to be signed every 2 years by patient. (even though for physician renewal no longer needed). this is an external link
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- "After filing this Affidavit with Medicare, download the Medicare Private Contract from your Medicare MAC website, and have each of your private Medicare clients sign this, notifying them that Medicare will not reimburse them."
This form is what I am looking for and would like to have in the portal to have client sign if they are medicare age. Is this what you have linked to above or is their a simpler form/notification clients can sign?
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Why is Simple Practice always a day late and a dollar short in providing support for new legal requirements affecting therapists? This was the same situation that occurred when the No Surprises Act/ Good Faith Agreement became a requirement not so long ago. As it stands, there has not even been an acknowledgement of the situation and an indication that SP is working on a private contract for therapists choosing to opt-out so we don't all have to make our own. SP should be AHEAD of the curve, not BEHIND it!
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Has anyone heard back on this? We can upload the form for Nordian into the intake docs, but that doesn't help because the client and clinician need to sign the document.
Here's the contract:
https://med.noridianmedicare.com/documents/10525/2052366/Opt-Out+Private+Contract.pdf
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Please, please, please, Simple Practice, add the Medicare private pay contract to your forms!
Colleagues, how have you managed this? Do I actually have to print out the forms and mail them to my clients for them to sign and mail back to me? I am seeing clients virtually, so if this has to be done by hard copy, I don't see another way. Some of my medicare clients are older (by definition!) and I think it's going to be too much tech to ask them to print, fill out, scan, and email back to me.
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Here's how I managed it: I took the Nordian contract and virtually copied it clause by clause with the SimplePractice form creation tool. All the client needs to do is check a box to sign it and it comes back into their portal just like any other form. The only problem is that there's no way for me to sign to electronically sign it myself. The workaround for that has been to download the client's signed form drop in my digital signature and date, upload it into their file and email them back a copy. It's still a little clunky but better than printing paper and sending back and forth through snail mail. It's made the whole thing pretty much a non-event.
If I could get this far with the rudimentary tools available to me, there's really no excuse that explains why SimplePractice couldn't do it better w/o all that much work. I'd be happy to share my form if I could, but I don't think there's a way to do it.
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Can someone please explain to me how to digitally sign the custom document I just created in the Assessments section? And then, how does my client sign it? Or can we just type our names into the spaces?
Oh! I see Erika just asked the same question. Glad to know I'm not the only one to whom this isn't obvious.
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Yes- thank you! One more question- I have tried different ways to save the assessment, but when you go to view it, it looks like one large paragraph: like the one below. Any tips on how to make it look better?
Section 4507 of the 1997 Balanced Budget Act allows a physician or practitioner to enter a private contract with a Medicare beneficiary. WHY A SPECIAL CONTRACT? I have not been excluded from providing medical services under Social Security Act Medicare (including sections 1128,1156, 1892, CFR § 405, subpart D. I Erika Forsyth, LMFT have chosen to separate myself (“opt out”) from Medicare. My current opt-out started January 1, 2024, and ends December 31st, 2025. Because I opted out, Medicare requires I have you sign a private-pay medical services contract before I treat you. WHO PAYS FOR SERVICES? You pay the bill. You will have to use your own money to pay the ENTIRE cost of my services. ARE THERE CHARGE LIMITS? No, Medicare charge limits DO NOT apply to products or services you receive from me through this private-pay medical services contract. I am able to charge you whatever amount you and I agree to. WILL MEDICARE HELP PAY? No, Medicare will NOT help pay your bill. Because I separated from Medicare, it is against the rules for you to send a bill to Medicare for my services or ask to send the bill to Medicare for you. BUT ISN’T THIS A MEDICARE-COVERED SERVICE? Yes and no. Yes, Medicare would pay for the same service from a provider who is connected to Medicare. No, Medicare won’t pay because I have separated myself from Medicare. WHAT OPTIONS DO I HAVE? You have the right to get your product or service from a provider connected to Medicare or from me, a provider separated from Medicare. Even if you get your product or service from me, you can always get products and services from providers connected to Medicare. These providers are not required to have you sign private-pay medical services contracts. WHAT IF I AM HAVING A MEDICAL EMERGENCY? This contract does NOT cover emergency or urgent care services. If you have an emergency or urgent medical need, ask me for help. It is against Medicare rules for me to have you sign a private-pay medical services contract for emergency or urgent medical services. WILL MY MEDIGAP OR OTHER SUPPLEMENTAL PLAN HELP PAY? No, Medigap plans WILL NOT help pay for products or services you get from me. If you have some other medical insurance plan, it MIGHT NOT help pay your bill either. WHAT ELSE DO I NEED TO DO? If you decide to sign this contract, make sure that I also sign the contract. It is also important you get a copy of the contract to keep. This way you will have a copy to look at if you have any questions about the contract in the future. WILL CMS GET A COPY OF THE CONTRACT? I, the provider, will supply a copy of this contract in the event CMS requests a copy.
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Actually, I spoke too soon. There IS a way to reclassify the form from an intake to an assessment. I just did that and it does allow me to sign my previous form but at the same time wiped out the field for the client to e-sign it that I had included. Does the field for the client to sign get appended to the form when an assessment is "shared"/sent?
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@Paul
Creating the Assessment template:
Settings > Notes and Forms > Assessments > create your template for the Medicare Private Pay contract > SaveSharing with a Client:
Go to client file > New (blue button beneath the Add Note text box) > Assessment > select the Medicare Private Pay contract
When complete, select Save > Sign > Share with client through the portal
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