Medicare/Medicaid Opt-Out Screening and Validation

As part of the changing healthcare landscape, more attention is being paid to providers who “opt out” of the Medicare (and soon to include Medicaid) programs. Individuals who are able to “opt out” of Medicare include doctors (medicine, osteopathy, optometry, pediatric medicine, dental surgery), physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, clinical social workers, and clinical psychologists.

If a healthcare practitioner chooses to opt out of Medicare, it means that he or she opts out for all covered items and services that he or she furnishes. Each Opt-Out contract lasts for a minimum two-year period beginning the date the practitioner files and signs an affidavit that he or she has opted out of Medicare. Participating Medicare providers can opt out at the beginning of each calendar quarter, and non-participating physicians can opt out at any time. If a provider “opts-out” of Medicare, he must contract privately with Medicare patients or beneficiaries to provide covered services.

As a dedicated provider of opt-out screening and validation services, OIG Compliance NOW is concerned about the potential for false claims for healthcare facilities due to the fact that opt-out providers who continue to submit claims to Medicare for services provided WILL STILL RECEIVE REIMBURSEMENT FOR THOSE CLAIMS.

Our Medicare/Medicaid Opt-Out program provides monthly screening checks, including validation, of the total number of Healthcare Practitioners submitted by any healthcare facility in any given month against the following lists:


  • All publically available state-level Medicare opt-out lists (currently all 50 states including two lists in California)

  • All publically available state-level Medicaid opt-out lists

As a healthcare facility, you would upload a data file of your healthcare practitioners once a month through your client portal, and our investigators would perform both screening and validation of any opt-out practitioners.

You would receive the following monthly reports from OIGCN:

  • Opt-Out Screening Summary report for Healthcare Practitioners list – this will outline screening statistics and indicate any unverified data, and will be sent electronically to the designated Provider contact upon completion.

  • List of Screened Healthcare Practitioners – this will accompany the Opt-Out Screening Summary report, and will include a list of all Practitioners that were successful screened for that particular month.

If you would like a presentation for you and your team about our opt-out provider screening program to outline our approach and discuss the positive impact our program would have on reducing risk for your organization, please contact us at (607) 240-2400.

For a Frequently Asked Questions document regarding Medicare Opt-Out, please click here.