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Opting Out of

Medicare

AAPS
Thrive Not Just Survive XXIV Workshop
Dallas, Texas
05-20-2016
Lawrence R. Huntoon, M.D., Ph.D.
Association of American Physicians and Surgeons

Reasons
for
Opting Out of
Medicare

Physician Burnout Climbs 10% in 3 Years,


Hits 55%
Professional burnout among US physicians has
reached a dangerous level, with more than half
of physicians affected, according to the results
of a 2014 national survey across various
medical specialties and practice settings.
Compared with responses from a similar survey
in 2011, burnout and satisfaction with work-life
balance have worsened dramatically, even
though work hours have not increased overall.
Physician Burnout Climbs 10% in 3 Years, Hits 55%
By Diana Swift
Medscape Neurology
December 1, 2015

Physician Burnout
The prevalence of burnout is higher in
physicians than in other professions and is
especially high in neurologists.
Physician
burnout
encompasses
3
domains:
(1)
emotional exhaustion: the loss of interest and
enthusiasm for practice; (2) depersonalization:
a poor attitude with cynicism and treating
patients
as
objects;
and
(3)
career
dissatisfaction: a diminished sense of personal
accomplishment and low self-value. Burnout
results in reduced work hours, relocation,
depression,
and
suicide.
Burned-out
physicians harm patients because they
lack empathy and make errors.
Physician Burnout: A Neurologic Crisis

EHRs are a Major Contributing Factor to


Physician Burnout
Physician frustration with poorly designed
EHRs, which consume an inordinate amount of
time and offer little or no benefit for patient
care, is a major contributory factor to physician
burnout.
Physicians who are burned out provide poor
patient care and have worse patient outcomes.
The Disaster of EHRs
Lawrence R. Huntoon, M.D., Ph.D.
Journal of American Physicians and Surgeons
Vol. 21 (2) Summer, 2016 pp. 35-37

Increasing Bureaucracy is
a Major Contributor
To

Physician Burnout

Medicare
Obstructs, Impedes, and
Interferes
with
Nearly Every Aspect
Of
The Practice of Medicine

I would really love to Opt Out of


Medicare

BUT
I really cant do it in my areaI am
surrounded by competitors all of whom
participate in Medicareand all of my
Medicare patients will leave and go to
my competitors if I Opt Out, and I will be
out of business.

Fear
of what MAY happen if you Opt Out of
Medicare or if you stop signing abusive
one-sided insurance contracts is the

FENCE
that confines you in the pen

The Pinky Toe Approach to Opting


Out
(Test the water temperature by dipping your
pinky toe in the water before diving into the
pool)
Conduct a brief written Survey of Medicare
patients as they come into your office.
Survey serves a dual purpose helps to
educate your patients about how the Medicare
bureaucracy adversely affects them, and
informs them about the substantial benefits of
being treated by an Opted Out Doctor.

The Medicare bureaucracy is increasingly forcing our


physicians to spend more and more time on
administrative requirements that having nothing to do
with providing you with quality medical care. Spending
more time on bureaucracy means spending less time
with individual patients. Medicare also coerces
physicians to serve as agents for rationing medical care
so as to save the government money. The Medicare
Program obstructs, impedes and interferes with our
ability to provide our patients with good care. Our
physicians do not want to serve as agents of rationing for
the Medicare program. In order to be able to provide you
with timely, individualized care and the face-to-face time
with your physician you deserve, our office is
considering rejecting this government abuse of our
patients and opting out of the Medicare program. Opting
out of Medicare means that you would pay reasonable
fees out of pocket and not be able to obtain
reimbursement from Medicare for the services our opted
out physicians provide. All other labs, tests, radiologic
studies and hospital care would be covered by the

Medicare Patient Survey


1.

2.

1. In view of the fact that government


interference in medicine will continue to
restrict our ability to provide you with the
quality care you deserve, would you be
willing to receive higher quality care
provided by an opted out physician? Any
Comments?
In view of the fact that you are already
paying substantial Medicare deductibles and
co-pays out- of-pocket for governmentrationed care, would you be willing to pay a
little more out-of-pocket to receive better
care? (getting in to see our physician
sooner, and having more face-to-face time
with our physician so that all of your
questions and concerns can be appropriately

Spending More Time with Patients as an Opted


Out Third-Party-Free Physician May Result in
Fewer Malpractice Claims

NY Times
http://www.nytimes.com/2015/06/02/upshot/to-be-sued-less-doctors-should-talk-topatients-more.html?_r=0&abt=0002&abg=0

To Be Sued Less, Doctors Should Consider


Talking to Patients More
JUNE 1, 2015
Doctors call it defensive medicine. They order extra tests, perform extra procedures or
push for more office visits because they think that without them, theyre at greater risk of
being sued. But studies dont support the notion that this extra precaution reduces their
risk. What might help physicians avoid being sued is getting along better with their
patients. Or at least, they could become better communicators.

Risk
Of
Prosecution, Prison
And
Ruinous Fines

Recovery Audit Contractors (RACs)


(Private Bounty Hunters)
Zone Program Integrity Contractors
(ZPICs) looking for crimes
FBI Health Care Fraud Task Force jurisdiction over both federal and state
insurance programs FBI has 56 field
offices
All in addition to the Medicare
contractors own fraud units and the

Effects of ObamaCare
Increased federal sentencing guidelines by 2050% for crimes over 1 million in losses
Increased license checks and site visits for
physicians deemed to be high risk for fraud and
abuse
CMS implemented advanced predictive
modeling technology to detect fraud
Provided an additional $350 million over 10
years to boost anti-fraud efforts

Spending More
Face- to-Face Time
with Patients
Makes for Much
Happier Patients

SGR
Defeated
(A Cause for Celebration?)

Small practices likely to be losers under


MACRA
http://medicaleconomics.modernmedicine.com/medical-economics/news/s
mall-practices-likely-be-losers-under-macra

CMS estimates that 87% of the nations solo practices


(nearly 103,000 physicians) will face a penalty in 2019,
the first year of the program, to the tune of $300 million.
The news is equally as pessimistic for practices of two to
nine physicians (an estimated 124,000 physicians) who
could see penalties to the tune of $279 million
There are winners and losers [in MACRA] and smaller
practices are more likely to be the losers, Lund told
Medical Economics. It appears the proposed rule would
create a penalty system where the big guys [larger
practices] will be funded by the little guys.
Small Practices Likely to be losers under MACRA
By Keith L. Martin

ObamaCare/MACRA Agenda
Like ObamaCare, MACRA is designed to
eliminate solo physician and small group
practices and force physicians into
hospital employment and/or large ACOs.
The goal is to eliminate fee-for-service
medicine and replace it with ACOs
subject to government control.
Centralized government control of
medicine is the ultimate objective.

962 Page Proposed Rule by CMS (Fed


Register 05/09/2016) for implementing
MACRA Merit-Based Incentive Payment
System (MIPS) and Alternative Payment
Model (ACOs)
https://www.federalregister.gov/articles/2016/05/09/2016-10032/medicare-prog
ram-merit-based-incentive-payment-system-mips-and-alternative-payment-modelapm

The physicians compliance score will be tied


to:
Effectiveness in rationing care so as to
conserve Medicare resources
Mandatory Meaningful Use of Certified EHRs
Rule will also allow all insurance-based care to
be phased in to these harmful payment models

MACRA April 16, 2015


(Medicare Access and CHIP Reauthorization Act of 2015)

106. Reducing administrative burden


and other provisions
Section 1802(b)(3) of the Social Security Act
(42 U.S.C. 1395a(b)(3)) is amended
(D) Applicable 2-year periods for effectiveness
of affidavits

(1) Indefinite, continuing automatic


extension of opt out election

Physicians Can Now


Permanently Opt Out of
Medicare!!!
Dr.
Huntoon
s Office

Also, physicians whose affidavits


are received after June 16, 2015 no
longer have to renew private
Medicare contracts every two
years.
Section 106(a) of MACRA indicates that valid opt-out
affidavits signed on or after June 16, 2015 automatically
renew every two years. Therefore, physicians and
practitioners that sign opt-out affidavits on or after June
16, 2015 will no longer be require to file renewal
affidavits or have their patients sign waivers [private
contracts] every two years.
Tamika Lyons
CMS Region II Office

Factors to Consider in Making Opt


Out Decision
Financial Considerations:
Need to consider the total revenue equation:
Gross Revenue Expenses = Net Revenue
2.
Need to look at type of services you provide, patient
population, and make an assessment about ability to
collect
directly from your patients
3.
If you elect to stay in Medicare, need to consider the
cost of you and your staff keeping up with everchanging Medicare rules and regulations, and the
cost of filing and handling Medicare claims + appeals
relative to revenue generated
4.
If you decide to Opt Out, may be helpful to find
niche services, if possible, and need to think about
how to develop a marketing campaign to inform
patients of the benefits of seeing an Opted Out
1.

MACRA
What will Happen to Physicians
Who Remain in Medicare?
Price Controls IPAB
Alternative Payment Models
Capitation on Steroids
(ObamaCare ACOs money paid to
Alternative Payment Models Not to
Individual Physicians)

Merit-Based Incentive Program


(Will Replace EHR Meaningful Use and
Physician Quality Reporting System (PQRS)

Under Merit-Based Incentive


Program Physicians Will be
Assigned a Composite Performance
Score (Minimal Rewards)

Non-Financial Considerations:
The freedom and pleasure of practicing medicine
again,
instead of practicing bureaucracy (Kick the Gorilla
out of
your Exam Room) happiness replaces physician
burnout
2.
Positive patient experience and protecting patient
privacy
3.
No fear of ruinous fines or prison time for inadvertent
coding
errors or running afoul of some obtuse Medicare law,
rule,
regulation (Medicare bounty hunters RACs, and
ZPICs no
longer a worry)
4.
Simplification Opt Out physicians need not use any
1.

In making your decision about


opting out of Medicare, you should
check all of your contracts and
hospital bylaws to insure that there
are no conflicts.
If you are unsure, ask an attorney
to review your contracts and any
other legal documents that may be
pertinent.

Procedure for Opting Out of


Medicare
Non-Participating physicians can opt out
of Medicare any time during the year. A
copy of the opt out affidavit must be
provided to the Medicare carrier(s) no
later than 10 days after the first contract
to which this affidavit applies is entered
into. (Tip it is highly recommended that
you provide the affidavit well in advance
of the planned start of the opt out period
i.e. Medicare bungling factor.) There
is a 90 day grace period after filing the 1 st
affidavit during which the physician may
withdraw the opt out affidavit. Be sure to
check other contracts and affiliations you

Participating Physicians can only opt


out four times during the year.
The Medicare contractor must receive
the opt out affidavit one month before
the beginning of next calendar quarter
(Jan 1, Apr 1, Jul 1, Oct 1).

Deadlines for carrier receiving opt out


affidavit: March 1st, June 1st, September
1st, and December 1st.

Opt Out Physicians Providing


Services in Urgent or Emergency
Situations
An Opt Out physician cannot make a new
contract with a Medicare patient in an
urgent or emergency situation.
An Opt Out physician who provides
services in an urgent or emergency
situation can file a claim with Medicare.
In that circumstance, the Opt Out
physician is treated like a Non-Par
physician in Medicare, and Non-Par
Allowed Amounts and Limiting Charges
apply.

Early Termination of Opt Out


Not have previously opted out of Medicare
Must notify all Medicare carriers of
termination of opt out no later than 90 days
after effective date of opt out
Must refund to each beneficiary with whom
practitioner has privately contracted all
amounts collected in excess of the Medicare
limiting charge
Must notify all beneficiaries with whom
physician entered into private contracts of
termination of opt out and beneficiaries
rights to have claims filed on their behalf for
services provided during opt out period
Physician is then reinstated to his prior
Medicare status as if there had been no opt out

You can download step-by-step


instructions for Opting Out, the Opt Out
Affidavit, Private Contracts for Use with
Patients, Sample Letters Informing
Patients of Your Decision to Opt Out, and
find answers to questions about Opting
Out on the AAPS Website at:
http://www.aapsonline.org/index.php/artic
le/how_to_opt_out_of_medicare/
You can also find on the AAPS website a list of
physicians by state who have Opted Out, videos of
talks given by Opt Out physicians about their
experience and tips for success, and a list of
physicians in various specialties who are willing to
serve as mentors and answer specific questions
regarding the Opt Out experience in their
specialty.

What About Hospitalizations, Labs,


Radiology Tests, Supplies and Home
Health Care?
Physicians who are currently in the Medicare
system either as a participating or nonparticipating physician, who opt out of
Medicare, have an NPI and are in the PECOS
database generally should have no trouble
having Medicare pay for hospitalizations, labs,
radiology services or home health care services

Website to Check to See if Physician is in


PECOS
http://www.oandp.com/pecos/

Medications and Referrals to


Specialists are Generally Excluded
from the Ordering and Referring
Rule
However, Opted Out Physicians
Who Do Not Have an NPI Cannot
Get Part D Drugs Covered by
Medicare

Physicians who have never enrolled in Medicare


do not have to enroll in Medicare in order to
Opt Out
Also, for physicians who are not enrolled in
Medicare or are Opted Out and not in the
PECOS database, there is a special abbreviated
enrollment form CMS 8550 you can use to
enroll in Medicare for the sole purpose of
ordering and referring
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloa
ds/cms855o.pdf

However, it requires that you obtain an


NPI in order to be listed in PECOS

If an Opt-Out provider elects to order and refer services,


Medicare contractors must develop for the following
information through an additional information request:
An NPI (if one is not contained on the affidavit
voluntarily);
Confirmation if an Office of Inspector General (OIG)
exclusion
exists (if not contained on the Affidavit);
Date of Birth; and
Social Security Number (if not contained on the
Affidavit).
If the above information is not obtained, the opt-out
provider will not be able to order and refer services. If
the opt-out provider refuses to report the information
listed immediately above, then the opt-out provider
cannot order and refer, but the failure to report this
additional information does not affect the providers right

AAPS also offers Thrive Not JUST


Survive Seminars a couple of times
per year at different locations
throughout the country (AAPS had
been running these workshops for 14
years)

See: AAPSonline.org for


Registration and Course Details
A tax-deductible donation
to our AAPS Educational
Foundation can help
expand our medical student
program

Tips for Opting Out:


1.

2.

3.

Start at least 6 months in advance of


beginning of Opt Out period. This provides
time to inform patients of changes, and time
for your staff to adjust. Filing the Opt Out
affidavit 6 months in advance of start date
also will allow for possible delays caused by
Medicare bungling.
Send a cover letter, certified mail, return
receipt, to Medicare carrier with the Opt Out
affidavit, requesting written
acknowledgement that the Opt Out has
been properly accomplished.
Office procedures in place so no Medicare
claims filed (except for emergencies)

If You Have Specific Questions


About Opting Out of Medicare or
Transitioning to a Third-Party-Free
Practice, Feel Free to Call AAPS

AAPS
1-800-635-1196