By: David Hirshfeld, Esq.
More and more of our seasoned clients are opting out of Medicare, and the younger ones are simply not enrolling. The scale seems to have finally tipped so that the potential liability of being a Medicare provider outweighs the benefits. So many providers are avoiding Medicare participation, that the Affordable Care Act and CMS have implemented the issuance of “Ordering and Referring Provider Numbers” through CMS Form 855-O.
As of May 1, 2013, physicians and other providers (collectively “Providers”) who bill Medicare must list the NPI of the ordering/referring Provider on their claim forms in order to be paid for the technical component of imaging services, the technical component of clinical laboratory services, durable medical equipment and/or home health services. An issue arises when the referring/ordering Provider does not participate with Medicare, and does not have an active NPI.
The Affordable Care Act provides a solution by allowing Providers to enroll in Medicare for the sole purpose of ordering or referring covered services for their Medicare patients, even though the ordering/referring Provider cannot bill Medicare for the services (s)he provides. This limited enrollment is accomplished through CMS Form 855-O.
Providers who have opted-out of Medicare by filing the required affidavit and entering into acceptable patient contracts do not have to submit Form 855-O as they have NPIs, even though they are not allowed to bill under them during their opt-out period.
Healthcare professionals today are constantly faced with views of what’s changing in healthcare, and all of them seem equally convincing. “One day, everyone will be employed by a hospital” is one of the favorites. Not surprisingly, the proponents of that perspective tend to be….hospitals. “Everyone has to merge their practices” is another favorite. The proponents? Large super practices, of course.
