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Greenville, SC 29601

317 St. Francis Dr.
Suite 350
Greenville, SC 29601
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Medicare Opt Out

Why Doctor Opted Out Of Medicare


I am a Greenville physician who specializes in physical medicine and rehabilitation, complex chronic pain, vascular and regenerative medicine, and serve on the medical staffs of Bon Secours St. Francis Health System and Greenville Health System University Medical Center.

Part and parcel of a physician’s soul is caring for the sick. It’s what motivates one to enter the medical profession. Yet, most citizens who have Medicare coverage today are finding fewer physicians who will accept Medicare patients. In fact, many physicians, including myself, are dropping out of the Medicare program altogether.

Why would a physician who has treated Medicare patients for over 15 years suddenly decide to opt out of the Medicare program?

The federal government, while possibly well intentioned, has now created such a complex maze of Medicare rules and regulations that compliance is practically impossible. By the time the physician figures them out, they have changed. By the time one realizes that they are not in compliance, they are audited.

At this point, the federal government is not concerned that the doctor was not aware of the dynamic rules and regulations. To them, the doctor is committing fraud and will be fined up to $10,000 per line item error.

To add to the frustration of keeping abreast of ever-changing rules and regulations, when a physician has a problem with Medicare, he does not know where to turn for help. Medicare is run by the Center For Medicare & Medicaid Services (CMS), also formally known as the Health Care Financing Administration (HCFA). Their main office is in Washington, D. C., but they have regional offices all over the United States. For example, South Carolina’s regional CMS office is in Atlanta.

Since the Medicare program is so large, CMS contracts with other companies to actually run the program. CMS calls these companies the Intermediary. In South Carolina, the Medicare Intermediary is a subsidiary of Blue Cross Blue Shield, called Palmetto Government Benefits Administrators.

Even the Intermediary admits that it has a hard time keeping abreast with all of the rules and regulations of CMS. They may make rulings against what would otherwise seem to be obvious CMS policy. If pointed out to them, don’t be surprised if they are deaf to the complaint.

If a physician provides care that they believe to be medically necessary and Medicare pays for it, but then Medicare later decides during an audit that is was unnecessary, the physician will be penalized. The most common and on-going disagreement between physicians and Medicare federal regulations revolves around the issue of was the care medically necessary?

Every patient contact becomes an encounter with choice: think first of the patient? Or of the system? It has gotten to the point where only in a minority of cases can the two needs be met simultaneously.

Mrs. Gray, a 65-year-old woman from Greenville, is a good example. She is a kind soul who suffers from chronic low back pain. Her X-rays reveal degenerative arthritis, and her neurologic studies show no evidence of nerve damage. Having not done well with treatments such as medicine by mouth or physical therapy, she is a very good candidate for an epidural steroid injection.

The South Carolina Medicare program has, however, decided that due to her absence of nerve injury, the service is unnecessary. Just a year earlier, when she had private insurance, the procedure would have been covered. Even if by some chance it was not, at least she could choose to pay for it herself. Now that she is on Medicare, however, she has no choice at all.

Since 1998 it has been against the law for doctors to privately contract with a Medicare patient even one time unless they file an affidavit with Washington stating that they will not file a single Medicare claim over the next two years. The procedure to file this “Opt Out” affidavit is subject to bureaucratic regulation.  Like many government run programs, the process is not a straight forward one.

Physicians are very cautious about patient care in this atmosphere. I, for one, am tired of honoring the Medicare system more than my patients’ needs. I welcome the possibility of establishing and renewing physician-patient relationships that are not invaded by federal rules and regulations which cannot be followed and appear only to prevent the delivery of care.

Hardly a day goes by without some form of the media reporting how the government has further eroded the personal choice of American citizens. All too frequently, the deepest erosion of personal choice is an intensely important one—Americans’ health care.

With legislative initiatives like the False Claims Act, the Kennedy Kassembaum Bill, HIPAA, HITECH, and now Obamacare, Americans are told they will be taken care of by the government. All is well. Our rights are preserved. When they go to the doctor, however, they find out that just the opposite is true.

Medicare participants discover that they are simply not offered everything that is available or are confronted with a list of services no longer available to them simply because they are in the Medicare system. Furthermore, while clearly there are those who will benefit from Obamacare, many who purchased insurance through the exchanges have already discovered reduced access and less robust coverage than they had anticipated.

A lack of accessibility for coverage has also infiltrated itself into what is left of non-government sponsored programs as well. Every day Americans find out that insurance company clerks (who may have no medical training) determine which health care services are eligible for coverage and that treatments as basic as generic medications that used to be covered before Obamacare no longer are. When coverage for a claim is denied, it has a distinctly detrimental impact on the physician-patient relationship.

The US Government has become the single largest payer of health care services, and Medicare still represents the lion share of its expenditures. Opting out of the Medicare program under the rules of the Kyl bill surely means lost opportunities for the physician. It is not an easy decision to make. There are, however, few basic truths more fundamental than the belief that preservation of life and liberty also includes the right to unrestricted freedom when it comes to one’s own health care.

Opting out allows the physician to place patient care ahead of federal rules and regulations. It empowers him to practice proactive medicine once again. Likewise for patients, fighting for the privilege to purchase health care services without government involvement can increase access, privacy, and self-determination.
Rather than unifying doctors and patients into a team to protect health care freedom rights, the doctor-patient relationship has deteriorated. The doctor is forgetting how to deliver, and the consumer is forgetting that they must show personal ownership in their health and that they should seek out patient-centered care.

It’s no surprise this has happened. What is a surprise is why so few know what to do about it. Individuals need to go into a doctor’s appointment prepared for the visit, and prepared to take responsibility for the entanglements that their third-party payer may bring with that visit.

Doctors need to remember that their first responsibility is to their patient. They need to demonstrate both empathy and decisiveness that reassures patients of their commitment to the patient’s well-being.

The doctor and the patient have to work together to fight against third-party interference with their relationship. They have to stop any further dismantling of this doctor-patient trust. It is important to repeal legislative provisions that serve to degrade that relationship and instead enhance opportunities that promote responsible choice.

It’s all about responsible choice. Both the doctor and the patient have to demonstrate the courage to commit to responsible choice, and to follow through with that commitment. Only then will the health care system function as it should.

A version of this article appeared in the Greenville News, Greenville, SC, January 8th, 1998