decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Medicare Overview / CMS Answers to Some Questions About Private Contracts
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Article Overview
This article provides a CMS question-and-answer overview of Medicare private contracts and the opt-out framework under the Balanced Budget Act of 1997. It is aimed at physicians, practitioners, compliance staff, coders, and billing teams who need to understand when private contracts are required, how opt-out affidavits work, what types of providers are affected, and how Medicare coverage rules interact with private payment arrangements and beneficiary notices.
Why This Topic Matters
The guidance helps practices evaluate whether services can be furnished outside Medicare participation, what documentation and filing steps are required, and how beneficiary rights and payment responsibilities change when a provider opts out. It is useful for avoiding claim-handling and contracting errors in situations involving private pay arrangements, referrals, urgent care, and services that may not be covered by Medicare.
What You Will Learn
- How Medicare private contracts relate to provider opt-out status
- Which types of professionals may or may not opt out under this guidance
- What filing and timing steps are associated with opt-out arrangements
- How beneficiary notices and noncovered services interact with private contracting
- How emergency, referral, and secondary-payer situations are addressed in the guidance
Who Should Read This
- Physicians
- Practitioners
- Medical office managers
- Billing and coding professionals
- Compliance staff
- Revenue cycle teams
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