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Medicare and Medicaid now in sync on ACA Rule

The Affordable Care Act requires physicians and other eligible non-physician practitioners that order, refer or prescribe for Medicare or Medicaid patients to enroll in Medicare and Medicaid unless a physician or other eligible non-physician practitioner decides to “opt out” of Medicare.

If a physician decides to “opt-out” of Medicare neither the physician nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician out-of-pocket and neither party is reimbursed by Medicare. A private contract is signed between the physician and the beneficiary that states that neither one can receive payment from Medicare for the services that were performed. The physician or practitioner must submit an affidavit to Medicare expressing his/her decision to opt out of the program.

(a previous post did not indicate the ability to opt out)


The rationale behind the ORP (ordering/referring providers) requirement is to ensure that all orders, prescriptions and referrals for items or services for Medicaid beneficiaries originate from appropriately licensed health care providers that have not been excluded from participation in Medicare or Medicaid.

Kentucky Medicaid will start the ORP process with a phase in period:

  • April 1, 2017: implementation date
  • April 1, 2017 – June 30, 2017: Billing providers will receive a notification on their remittance advice every time a claim is submitted and the ORP provider is not enrolled with Kentucky Medicaid
  • July 1, 2017: Claims that do not meet the ORP requirements are denied

Historically, most providers enroll in the Medicaid program to furnish covered services to Medicaid recipients; health care providers already enrolled as active Medicaid billing providers do not need to enroll again as an ORP provider.

While the requirement has positive intentions, it could create an administrative burden that could potentially impact payments in certain situations that include:

  • Out-of-state ordering, referring and/or prescribing providers must also enroll in Kentucky Medicaid for services to be paid.
  • Items or services ordered, prescribed or referred by a resident or intern must identify the teaching physician as the ordering or referring provider on the claim using his or her legal name and National Provider Identifier (NPI) and he or she must be an enrolled Medicaid provider.

Read more about Opt-Out

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