Participating Physicians and Practitioners

40.17 - Participating Physicians and Practitioners (Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13) Participating physicians and practitioners may opt out if they file an affidavit that meets the criteria and which is received by the Medicare contractor at least 30 days before the first day of the next calendar quarter showing an effective date of the first day in that quarter (i.e., January 1, April 1, July 1, October 1). They may not provide services under private contracts with beneficiaries earlier than the effective date of the affidavit. The 30-day notice is required to allow sufficient time for the Medicare contractor to accomplish the appropriate system file updates before the effective date. The Medicare contractor must make participating physician status changes no less frequently than at the beginning of each calendar quarter. Therefore, participating physicians or practitioners must provide the Medicare contractor with 30 days notice that they intend to opt out at the beginning of the next calendar quarter. Participating physicians or practitioners may sign private contracts only after the effective date of affidavits filed in accordance with §40.9. They may not provide services under private contracts with beneficiaries earlier than the effective date of the affidavit. It is necessary to treat nonparticipating physicians or practitioners differently from participating physicians or practitioners in order to assure that participating physicians or practitioners are paid properly for the services they furnish before the effective date of the affidavit. Participating physicians or practitioners are paid at the full fee schedule for the services they furnish to Medicare beneficiaries. However, the law sets the payment amount for nonparticipating physicians or practitioners at 95 percent of the payment amount for participating physicians or practitioners. Participating physicians or practitioners who opt out are treated as nonparticipating physicians or practitioners as of the effective date of the opt-out affidavit. When a participating physician/practitioner opts out of Medicare, the Medicare contractor must pay the physician/practitioner at the higher participating physician/practitioner rate for services rendered in the period before the effective date of the opt-out; and at the nonparticipating rate for services rendered on and after the opt-out date.