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Medicare Opt Out Form?

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36 comments

  • Susan Orenstein, PhD

    I have the same question.  This would be great information to have.

    And I have an additional question--how do you renew the opt-out process with Medicare?  And how often is it necessary to renew this?

     

    Thanks!!

     

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  • Corrie Goldberg

    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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  • Susan Orenstein, PhD

    thanks!

     

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  • Sanjeev Singhal MD

    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

    https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwjY0OyXjcbkAhVNm-AKHauEBpoQFjAAegQIARAC&url=https%3A%2F%2Fwww.aafp.org%2Fdam%2FAAFP%2Fdocuments%2Fpractice_management%2Fregulatory_compliance%2FMedSampContractAff.doc&usg=AOvVaw1fSmpf48T37gwKP5xWqIRF

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  • Susan McDonald-Conroy
    • "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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  • Jennifer Hewitt

    We need this Form please

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  • Paul Howard, MFT

    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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  • Alicia Dabney

    Adding my voice to the mix that we need a Medicare private contract template! 

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  • Nicole Vykoukal, LCSW

    Following, as I would like the option of accessing a Medicare opt-out contract client-clinician form in Simple Practice.

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  • Mary Deggelman

    Also requesting that SP get on a Medicare opt out form for private pay clients. This would be helpful so our 65 plus clients don't need to print, sign and upload contract.

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  • Britney Cirullo

    Adding to this request, PLEASE!!! We need a form. Be ahead of the curve, not behind.

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  • Erika Forsyth

    I agree.  Please add a Medicare opt-out contract client-clinician template form in Simple Practice (for both client and clinician to sign).  

     
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  • Karla Schlags

    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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  • Emily Shapiro

    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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  • Paul Howard, MFT

    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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  • Erika Forsyth

    Brilliant.  Thank you!!

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  • Alicia Dabney

    @Paul 

    I used the same method to create a custom template, but if you do it in assesments (like where the GFE is located), you can digitally sign it, then hit "share" and send it to the client to sign. Both signatures are then in place! 

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  • Emily Shapiro

    Thank you so much, Paul and Alice! This is a brilliant workaround! 

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  • Erika Forsyth

    Alicia- if you have a minute, may you please share how you added your digital signature in the assessment form before sharing it with the client to sign? 

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  • Emily Shapiro

    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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  • Alicia Dabney

    Assessments are a type of document that can be signed and locked just like Session Progress Notes. I sign it first, then go share it as a file to the client for them to review and sign. 

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  • Paul Howard, MFT

    Thanks to Alicia for providing the missing link that I didn't think existed. Only problem for me is that I probably have to recreate the form all over again as an Assessment.  Unlesssss, there's a way to reclassify the one I already made.  I sorta doubt it.

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  • Erika Forsyth

    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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  • Emily Shapiro

    I typed each paragraph as a separate "question" on the "assessment." I chose a kind of question called something like a "paragraph form (no client response)" This way it doesn't all run together. 

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  • Paul Howard, MFT

    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 Howard, MFT

    @Erika, Yes, I created the clauses the same way that Emily mentioned.

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  • Alicia Dabney

    @Paul

    Yes! The field for the client to sign gets appended to the form when you send it to them. 

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  • Paul Howard, MFT

    @Alicia,  I'm not sure what I'm missing but am still having problems seeing how I can sign an assessment before I send it to the client.  Can you spell out the steps for me please?

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  • Alicia Dabney

    @Paul

    Creating the Assessment template:
    Settings > Notes and Forms > Assessments > create your template for the Medicare Private Pay contract > Save

    Sharing 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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  • Paul Howard, MFT

    @Alicia.  That did the trick!  Thank you so much.  I'm glad to have this behind me once and for all.

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