Providers Opted Out of Medicare

Access information on providers who have decided not to participate in Medicare.

Usage

opt_out(
  npi = NULL,
  first = NULL,
  last = NULL,
  specialty = NULL,
  address = NULL,
  city = NULL,
  state = NULL,
  zip = NULL,
  order_refer = NULL,
  tidy = TRUE,
  ...
)

Arguments

npi

< integer > 10-digit Opt-out National Provider Identifier

first, last

< character > Opt-out provider's name

specialty

< character > Opt-out provider's specialty

address

< character > Opt-out provider's address

city

< character > Opt-out provider's city

state

< character > Opt-out provider's state abbreviation

zip

< character > Opt-out provider's zip code

order_refer

< boolean > Indicates order and refer eligibility

tidy

< boolean > // default: TRUE Tidy output

...

Empty

Value

A tibble with the columns:

Field	Description
npi	10-digit NPI
first	Opt-out provider's first name
last	Opt-out provider's last name
specialty	Opt-out provider's specialty
order_refer	Indicates if the provider can order and refer
optout_start_date	Date that provider's Opt-Out period begins
optout_end_date	Date that provider's Opt-Out period ends
last_updated	Date information was last updated
address	Opt-out provider's street address
city	Opt-out provider's city
state	Opt-out provider's state
zip	Opt-out provider's zip code

Opting Out

Providers who do not wish to enroll in the Medicare program may “opt-out”, meaning neither they nor the beneficiary can bill Medicare for services rendered.

Instead, a private contract between provider and beneficiary is signed, neither party is reimbursed by Medicare and the beneficiary pays the provider out-of-pocket.

To opt out, a provider must:

• Be of an eligible specialty type

• Submit an opt-out affidavit to Medicare

• Enter into a private contract with their Medicare patients, reflecting the agreement that they will pay out-of-pocket and that no one will submit the bill to Medicare for reimbursement

Opt-Out Periods

Opt-out periods last for two years and cannot be terminated early unless the provider is opting out for the very first time and terminates the opt-out no later than 90 days after the opt-out period's effective date.

Opt-out statuses are also effective for two years and automatically renew. Providers that do not want to extend their opt-out status at the end of an opt-out period may cancel by notifying all MACs an affidavit was filed at least 30 days prior to the start of the next opt-out period.

If a provider retires, surrenders their license, or no longer wants to participate in the Medicare program, they must officially withdraw within 90 days. DMEPOS suppliers must withdraw within 30 days.

Providers may NOT opt-out if they intend to be a Medicare Advantage (Part C) provider or furnish services covered by traditional Medicare fee-for-service (Part B).

Update Frequency: Monthly

References

• Medicare Opt Out Affidavits API

Examples

if (FALSE) { # interactive()
opt_out(npi = 1043522824)

# For opt-out providers eligible
# to order and refer, use [order_refer()]
# to look up their eligibility status:

opt_out(npi = 1043522824) |>
        pull(npi) |>
        map(\(x) order_refer(npi = x)) |>
        list_rbind()
}