Physicians or Practitioners Who Choose to Opt Out of Medicare

40.18 - Physicians or Practitioners Who Choose to Opt Out of Medicare (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16) If a physician/practitioner chooses to opt-out of Medicare, it means that the physician/ practitioner opts-out for all covered items and services that he or she furnishes. Physicians and practitioners cannot have private contracts that apply to some covered services they furnish but not to others. For example, if a physician or practitioner provides laboratory tests or durable medical equipment incident to his or her professional services and chooses to opt-out of Medicare, then the physician/practitioner has opted out of Medicare for payment of lab services and Durable Medical Equipment, Prosthetics, and Orthotics (DMEPOS) as well as for professional services. If a physician or practitioner has a valid opt-out affidavit on file with the MAC, has a valid NPI, is a specialty that is eligible to order or certify, and refers a beneficiary to a non-opt-out physician or practitioner for medically necessary services, such as laboratory, DMEPOS or inpatient hospitalization, Medicare would cover those services. In addition, because suppliers of DMEPOS, independent diagnostic testing facilities, clinical laboratories, etc., cannot opt-out, the physician or practitioner owner of such suppliers cannot opt-out as such a supplier. Therefore, the participating physician or practitioner becomes a nonparticipating physician or practitioner for purposes of Medicare payment for emergency and urgent care services on the effective date of the opt- out. (See §40.28).