To Opt out or Not To Opt Out, That is the question. Physicians must discuss and decide.

May 5, 2016

Hello Dear Concerned Colleagues,

I agree with Dr. Jane that Medicare patients (as have we all who have worked in the US) have had money taken from their paychecks their entire lives and are in effect conscripts in the Medicare Army; however, as we all know, government flagrantly broke the promise it made to not interfere whatsoever with the practice of medicine whatsoever including the administration and financial aspects.

Presently, government is expanding its conscription of seniors to include all patients who have healthcare insurance, whether it is Medicare, Medicaid, or Commercial via MACRA.

The Feds made buying insurance a federal law, so the only people free of their conscription are lawbreakers, who resisted buying the insurance and instead are penalized.

At any rate, is it the physician’s duty to enable the system effectively sanctioning government’s broken promises, overreach, and failed plans? Or is our duty to better serve our patients by refusing to do so, as we innovate and forge new and better ways to care for our sick. I contend the latter.

Fact is, in ophthalmology (as I’m sure with every specialty) there is incredible technological advancement abounding- including intraocular lenses that correct refractive error at the time of cataract surgery and laser cataract surgery that not only corrects astigmatism but is shown by numerous studies to produce more predictable outcomes and is safer for patients with a clinically significant decrease in occurrence of capsular tears and other intraoperative complications.

Yet, Medicare covers none of this for patients- only old style lenses and no laser technology. Patients who desire such technology must pay on their own over and above what Medicare charges. I have developed a fee schedule whereby I can do the cataract operation utilizing the new laser technology and lenses for close to what they end up coming out of pocket for if they do see a Medicare participating provider. My fees are transparent and reasonable. Patients can choose to stick with what government spoons out or upgrade and stay in my care for the perceived and real value of our patient-physician relationship, accessibility, utilization of state of the art care, and most importantly freedom from government unproven rationing, denial, restriction, data collecting, and overall violation of their medical care.

Further, I believe few doctors understand the complex Medicare insurance system. For example, I have a group of Medicare patients who have AETNA as a secondary insurer whose benefits cover 100% when they see an opted out physician and file out of network with their AETNA secondary policy. Even Tricare covers 20% if they see me opted out and then file. Supplements will not provide out of network benefits in most cases, BUT Medicare Advantage plans WILL provide out of network benefit up to 80% in many cases. Also, the patient can use their Part B to cover the ASC costs of goods and services and anesthesiologist if he/she has not opted out. Worst case scenario it costs them $800.00 to have me do their operation including 3 months post op care. If they choose laser or lens upgrade it costs them the same or less than seeing someone else who accepts assignment. I know this is complex, but we must know what is going on to best work for our patients within the existing system as we create the way to work without. At times I feel we’re headed toward an underground railroad for patients of sorts.

Yesterday I saw a Medicare patient who is experiencing a severe exacerbation of her rheumatoid arthritis that chooses to see me- as she waits 7 months to get in with a participating rheumatologist. She calls their office daily for a cancellation and has been able to get her appointment moved up to 5 weeks from now. This is Canada/VA style delays or worse. I am seeking an opted out rheumatologist with a reasonable fee schedule she can see- there’s not one in San Antonio. Think about that a second. The Medicare HMO patient must wait months to see the assigned Medicare HMO doctor. All other Medicare providers not in her HMO would be committing fraud if they saw her-she can only get in and see me because I have opted out. I could go on… I have given this heart wrenching thought and believe I’m serving the “conscripts” better because I have opted out.

I have more time with my patients, who value me- they don’t just regard me as an entitlement. I feel better physically, mentally, and spiritually.

My bank account and surgical volume doesn’t look better, but I’m working on that as I learn more, educate more, and  move my new practice model forward.

I love the dialogue we are all having now. I have never felt better than being out from the government boot and able to freely and individually see my patients. Amazingly, opted out, it is even legal for me to choose to see them for free. Yes, it is a perverse system. I feel a little less perverse, a little less oppressed and abused. It takes immense communication and education of patients and staff, but it can and must be done. My patients thank me and ask why more doctors don’t do the same.

I fear the central planners will continue to close doors on our underground railroad but until then I’m digging new tunnels as fast as I can. I hope and pray there is a massive movement of physician colleagues to jump on the train with me.

Best to all,




14 thoughts on “To Opt out or Not To Opt Out, That is the question. Physicians must discuss and decide.

  1. There are some good alternatives mentioned here for doctors to get around the fact that they have opted out of Medicare and still treat at least some Medicare patients with secondary insurance.

  2. I opted out of all 3rd party payment in the past 3 yes and without any formal courses or directives on how to do it. In the space of one month a few yrs ago, I sat with each patient myself and explained briefly why I was doing it. Very few of them even understood that physicians do not receive the balance of their charged fees after they pay their co- pays. They do not read or understand their EOB’s. Most were shocked at this revelation. Many wanted to reimburse me what was discounted over many years. Of course this was not accepted. I have not accepted Medicare or Medicaid in about 12 years . Still all insurance companies including the federal programs pay their usual reimbursements to such services as labs, radiology and pharmacies even though I am no longer a provider and have NO provider number. ???? The bottom line is my income has increased, the patients receive their services drugs, labs and equipment . They do not object to my fees which they pay 100 per cent. The stress on me and my staff has plummeted to zero. I am in charge of my own solo practice , there are no accounts receivable and cash flow flows on a day to day basis without answering to insurance inquiries reviews . I have been in primary care practice for over 40 years and for the first time , enjoying it . There’s no smoke or mirrors— everyone practicing medicine CAN DO IT !!!!!

  3. I’ve thought about opting out but operate at two local hospitals and do not have an ASC or venue by which I can do cataract surgery otherwise. I’m following with interest the recent articles about in office cataract surgery and wonder what regulations there will be. I’d be interested in how you went about opting out and the pros and cons. I suppose the upcoming meeting in Texas would be best but personal items prevent me from attending. Any suggestions for reading? I read the AAPS newsletters.

  4. Thanks for posting this, Kris. I feel your angst as the same entanglements and challenges exist for me as a third-party free primary care doc. I agree about the “underground medical railroad”. The only card we have to play is massive, widespread opt-out. And, the only card Washington, DC has is to outlaw non-participation, making participation mandatory for licensing. The loopholes and escape hatches for docs and patients will close fast is we don’t act swiftly.

  5. All of you opted-out ophthalmologists should start your own surgery center modeled after SCO in Oklahoma City and tell the big giant hospitals to take a hike! In fact, a third-party free multi-specialty clinic complete with surgery center and imaging/lab is my dream some day.

  6. I applaud you. I have been opted out for over 3 years and have never looked back. I do however still take insurance and angst at every merger that the feds continue to allow. Single party payer is what they would like to force on us. I wish all physicians were like you and had courage.

  7. Thanks Kris.
    It is my opinion that leaving Medicare will be inevitable as MACRA unfolds. In my town nearly every patient in Medicare is seen and managed by an extender. While subtle this is our physicians informing patients Medicare’s fee structure and regulation is not working for us.
    As we continue to agree with these insurance contracts and the conscription of Medicare we perpetrate the Myth that 3rd party payment and involvement is necessary (fodder for the political argument).
    Nothing in PPACA mandates doctors sign contracts. Don’t sign and the leverage on us and patients disappears. Fear of the governments next move should not cause us not to act. The fence around our prison is imaginary.

    • Thank you for your reply Raymond. I knew I had no choice but to opt out after reading MACRA last year. After reading the recently published proposed rules related to MACRA, I was stunned at the increased speed, aggressiveness, and iron-fisted tone the rule makers were going forward with. If our colleagues will act we can stop this, if we don’t we are to blame. We must overcome the fear with our call to work for the good of our patients. I am relieved I opted out of this losing game. I encourage everyone else to do so as well. Your comments are right on target.

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