Private Contracts Between Beneficiaries and Physicians/Practitioners (Emergency and Urgent Care Situations)In an emergency or urgent care situation, payment can be made for services furnished to a Medicare beneficiary provided the beneficiary has not signed a private contract with an "opt out" physician/practitioner. We are providing addi-tional information on emergency and urgent care situations below. Emergency or Urgent Care Situations Payment may be made for services furnished by an "opt out" provider who has not entered into a private contract with a Medicare beneficiary for emergency or urgent care situations. The provider must submit a claim to Medicare and may collect no more than the Medicare limiting charge in the case of a physician who does not accept assignment or the deductible and coinsurance, in the case of a practitioner or a physician who wishes to accept assignment. A private contract may not be entered into when the beneficiary is in need of emergency or urgent care. The physician/practitioner must submit acompleted Medicare claim on behalf of the beneficiary with the appropriate HCPCS code and HCPCS modifier which indicates the services furnished to the Medicare beneficiary as an emergency or urgent and the beneficiary does not have a private agreement with him/her. The GJ national HCPCS modifier is needed in this situation. GJ= "OPT OUT" PHYSICIAN OR PRACTI-TIONER EMERGENCY OR URGENT SERVICES. Under the emergency and urgent care situation, when an "opt out" physician or practitioner renders emergency or urgent care service to a Medicare beneficiary (e.g., treatment for a fractured leg) who has not entered into a private agreement with him/her, the physician is required to submit a claim to Medicare with the appropriate modifier (GJ and 54) and is subject to all Medicare regulations including limiting charge. If, however, the "opt out" physician/practitioner asks the beneficiary to return for a follow up visit (i.e., return within 5 to 6 weeks to remove the cast and examine the leg), the physician/practitioner shall ask the beneficiary to sign a private contract. Once a beneficiary no longer needs emergency or urgent care, Medicare cannot pay for the follow up care and the physician/practitioner can and must, under the "opt out" affidavit agreement, ask the beneficiary to sign a private agreement as a condition of further treatment. For example, the physician/practitioner would bill Medicare for the setting of the fractured leg with the emergency "opt out" HCFA modifier (GJ) and the surgical care only modifier (54). The physician/practitioner would then either have the beneficiary sign the private contract or refer the beneficiary to a Medicare physician/practitioner. Of course, it would be different if the beneficiary continues to be in a condition that requires emergency or urgent care (i.e., unconscious or unstable after surgery). In such a case, the follow up care would continue to be paid under emergency or urgent care until such time as the beneficiary no longer needed such care. Emergency or urgent care services are defined as being services furnished to an individual who has an emergency medical condition. Urgent care service could be any service that needs to be furnished within 12 hours after the determination of need is made to avoid adverse health consequences. Additional questions and answers regarding Private Contracts can be found in The Medicare News Brief 98-3. |
