Written Policy Guidance Sought on Medicare Patients Billed Directly by Unenrolled Physicians

Physician organizations, including the NCMS and other state medical societies, have asked the Centers for Medicare and Medicaid Services (CMS) for written public policy guidance on how patients enrolled in Medicare may obtain reimbursement for covered services provided by physicians who are not enrolled in Medicare and bill their patients directly.

In a letter to Acting CMS Administrator Marilyn B. Tavener, the organizations state that Medicare materials typically describe three alternatives: being a participating physician, being a non-participating physician, or opting out of Medicare and privately contracting with patients who are enrolled in Medicare.

“Questions have recently been raised within the physician community about a fourth option, whereby physicians who do not enroll as Medicare providers bill their patients directly at fee levels that are set without regard to Medicare payment rates or limiting charges. Medicare patients pay the physician bills out of pocket and then seek reimbursement from Medicare using form CMS-1490S,” according to the letter.

The organizations note that electronic e-mail correspondence reveal, “it is the view of the CMS that the option of having physicians not enrolled in Medicare and having beneficiaries submit claims on their own using the form CMS 1490S is not consistent with Medicare law and un-enrolled physicians who engage in this type of practice are subject to penalties.”


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1 Comment

  • Sandra Brown MD

    I do not see that physicians are engaging “in this type of practice”. Rather is is patients who are electing to see a physician whom they know in advance has no relationship with medicare. What the patient does with a piece of paper is their own business.