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Report (OEI-07-11-00340)

01-26-2012
Lack of Data Regarding Physicians Opting Out of Medicare

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Summary

Why We Did This Study

In April 2011, we began an evaluation entitled Impact of Physicians Opting Out of Medicare. The objectives of the evaluation were to determine the extent to which and reasons why physicians opt out of the Medicare program and the effects of physician opt out on Medicare beneficiaries. In the course of our review, we determined that CMS, Medicare Administrative Contractors (MACs), and legacy carriers (i.e., Medicare claims payment contractors that remain in jurisdictions not yet awarded to MACs) do not maintain sufficient data regarding physicians who opt out of Medicare. As a result, we were unable to conduct the proposed evaluation at this time.

How We Did This Study

We sought to obtain data on opted-out physicians both from CMS and from individual MACs and legacy carriers. A CMS official provided us with a list of approximately 7,900 opted-out providers (e.g., physicians and nonphysician practitioners), which included opted-out providers from 1998 to March 2011. However, the CMS official indicated that he created this list using the lists of opted-out providers posted on MAC and legacy carrier websites. The CMS official stated that, for our purposes, the MACs and legacy carriers would have the best available data on opted-out physicians. In July 2011, we requested information regarding opted-out physicians for the period January 2009 through June 2011 from all 10 MACs and 6 legacy carriers that pay Part B Medicare claims.

What We Found

We were unable to answer the issue questions in our proposed study because no centralized data exist and the data that we received from MACs and legacy carriers were insufficient or not provided at all. Specifically, we cannot determine the characteristics of physicians who opt out of Medicare, the trend in the number of opted-out physicians, and why physicians choose to opt out of Medicare.

What We Recommend

The quality of the data and lack of procedures for MACs' handling of opted-out physicians impedes CMS's oversight of this aspect of the Medicare program. Although we acknowledge that the CMS guidance issued in 2011 addresses the procedures that MACs and legacy carriers must have in place for maintaining data on physicians who opted out on or after January 1, 2009, we believe that further direction is necessary to account for data on physicians who opted out between 1998 and 2008. We plan to conduct a full evaluation when a complete data source of opted-out physicians is available.

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