If I Opt Out, Can My Patients Still Get Labs Covered?

If you’re a healthcare provider considering opting out of Medicare, you might wonder: Will Medicare still cover lab tests I order for my Medicare patients? This is a common concern among providers, and understanding the nuances of Medicare opt-out rules can help you make informed decisions.

Here’s what you need to know:

The Basics of Medicare Opt-Out

When you choose to opt out of Medicare, you are essentially signaling that you will not bill Medicare for your services. However, when completing the opt-out affidavit—a form provided by your Medicare Administrative Contractor (MAC)—you have the option to check a box indicating whether you wish to remain an ordering and certifying provider.

This designation allows you to order labs, write prescriptions, or refer Medicare patients to specialists without disrupting Medicare coverage for those services.

What Happens If You Check “Yes” to Being an Ordering and Certifying Provider?

If you opt out of Medicare and check the box to remain an ordering and certifying provider, then:

1. Medicare Coverage for Labs, Prescriptions, and Referrals: When you order lab tests, write prescriptions, or make referrals for Medicare patients, these services will still be covered by Medicare, provided the third party (e.g., the lab, pharmacy, or specialist) accepts Medicare and the service is eligible for Medicare reimbursement.

2. Ease for Your Patients: Your Medicare patients won’t face unexpected issues with coverage for these services, even though you have opted out.

What If You Don’t Check the Box?

If you don’t check the box to remain an ordering and certifying provider when opting out, Medicare will not cover the services you order or refer for Medicare patients. However, this situation can be remedied.

How to Correct Your Status

If you opted out without checking the box—or you were never enrolled as an ordering and certifying provider—there are steps you can take to fix it:

1. Submit CMS Form 855O
   Use this form to enroll solely as an ordering and certifying provider, even if you’ve opted out of Medicare. It ensures you can continue ordering and certifying services for Medicare patients while remaining opted out for your personal services.

2. Check CMS Form 855I
   In some cases, this form may also be applicable, depending on your practice's structure and needs. It’s worth reviewing both forms to determine which suits your situation.

Checking Your Medicare Status

If you’re unsure about your current Medicare status, you can verify it in one of two ways:

1. PECOS System: Use the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) to check your status.

2. CMS Public Databases: Medicare maintains public databases where you can look up your status using your NPI number or name. These databases also indicate whether you are listed as an ordering and certifying provider. You can find these resources on cms.gov.

Resources for Providers

If navigating Medicare’s processes feels overwhelming consider joining the Origins Incubator Program. We tackle questions like these during our weekly legal office hours, providing clarity on Medicare, practice creation, clinical mentorship, and more.

By staying informed and proactive, you can ensure a seamless experience for your Medicare patients while maintaining your desired practice structure.