The Medicare caller who wants to pay cash: what has to be true first

Does not being enrolled put you outside Medicare?

Not by itself. The claim duty is written to the service, not to your billing posture. Social Security Act section 1848(g)(4) reaches all physicians and suppliers who furnish covered services to Medicare beneficiaries, whether or not assignment was accepted, and skipping that claim can draw a civil monetary penalty of up to $2,000 per violation, program exclusion, or both 1Ref 1Noridian Healthcare Solutions (CMS Medicare Administrative Contractor, Jurisdiction E Part B) (2025).Mandatory Claim Submission - JE Part B.The Social Security Act section 1848(g)(4) duty on all physicians and suppliers to submit a claim for every covered service furnished to a Medicare beneficiary regardless of assignment, and the civil monetary penalty of up to $2,000 per violation or program exclusion for failing to do so..

What the guidance does not say is how that duty reaches a clinician Medicare holds no record of, which is the question this page returns to.

Non-participation and non-enrollment get used as though they were one posture. They are two. For a covered service you intend to be paid for privately, the route the rules provide is a formal opt-out paired with a written private contract signed by the beneficiary, and both halves have to be done correctly before either one counts 2Ref 2Centers for Medicare & Medicaid Services, HHS (codified regulation) (2021).Code of Federal Regulations, Title 42—Public Health, Chapter IV, Part 405, Subpart D—Private Contracts (§§ 405.400–405.415).The regulatory definitions of opt-out and private contract, the 10-day affidavit filing deadline for a nonparticipating physician or practitioner and the calendar-quarter route with a 30-day filing lead for a participating physician, the two-year opt-out period running from the affidavit's signing date, the delayed start when the affidavit is filed late together with the standard-rules treatment of care furnished before that filing, and the rule that a defective contract or a failure to remain in compliance voids both the private contract and the opt-out so the encounter reverts to standard Medicare rules..

So the caller's question splits. One part is what you may charge, which the private contract settles in a single clause. The other part is whether you are in a position to use that clause at all, and that turns on a filing you have either made or not made.

Opting out is a filing with a clock on it

Opt-out is an election with a deadline attached, and the deadline is the part that goes wrong. A nonparticipating physician or a practitioner signs a first private contract with a Medicare beneficiary, then files an affidavit with each Medicare Administrative Contractor that would otherwise process the claims. The two-year opt-out period runs from the date that affidavit was signed, so long as it is filed within 10 days of that first signed contract 2Ref 2Centers for Medicare & Medicaid Services, HHS (codified regulation) (2021).Code of Federal Regulations, Title 42—Public Health, Chapter IV, Part 405, Subpart D—Private Contracts (§§ 405.400–405.415).The regulatory definitions of opt-out and private contract, the 10-day affidavit filing deadline for a nonparticipating physician or practitioner and the calendar-quarter route with a 30-day filing lead for a participating physician, the two-year opt-out period running from the affidavit's signing date, the delayed start when the affidavit is filed late together with the standard-rules treatment of care furnished before that filing, and the rule that a defective contract or a failure to remain in compliance voids both the private contract and the opt-out so the encounter reverts to standard Medicare rules..

A participating physician has a different route: opt-out takes effect at the start of a calendar quarter, with the affidavit filed at least 30 days before that quarter begins 2Ref 2Centers for Medicare & Medicaid Services, HHS (codified regulation) (2021).Code of Federal Regulations, Title 42—Public Health, Chapter IV, Part 405, Subpart D—Private Contracts (§§ 405.400–405.415).The regulatory definitions of opt-out and private contract, the 10-day affidavit filing deadline for a nonparticipating physician or practitioner and the calendar-quarter route with a 30-day filing lead for a participating physician, the two-year opt-out period running from the affidavit's signing date, the delayed start when the affidavit is filed late together with the standard-rules treatment of care furnished before that filing, and the rule that a defective contract or a failure to remain in compliance voids both the private contract and the opt-out so the encounter reverts to standard Medicare rules..

File late and the period does not start until the last required affidavit is filed, and care given before that filing sits under standard Medicare rules 2Ref 2Centers for Medicare & Medicaid Services, HHS (codified regulation) (2021).Code of Federal Regulations, Title 42—Public Health, Chapter IV, Part 405, Subpart D—Private Contracts (§§ 405.400–405.415).The regulatory definitions of opt-out and private contract, the 10-day affidavit filing deadline for a nonparticipating physician or practitioner and the calendar-quarter route with a 30-day filing lead for a participating physician, the two-year opt-out period running from the affidavit's signing date, the delayed start when the affidavit is filed late together with the standard-rules treatment of care furnished before that filing, and the rule that a defective contract or a failure to remain in compliance voids both the private contract and the opt-out so the encounter reverts to standard Medicare rules.. A defective opt-out is a different failure. Where the contract is missing required contents, or the clinician does not stay in compliance during the opt-out period, the contract and the opt-out are both null and void, and the encounter reverts to ordinary Medicare coverage and billing rules 2Ref 2Centers for Medicare & Medicaid Services, HHS (codified regulation) (2021).Code of Federal Regulations, Title 42—Public Health, Chapter IV, Part 405, Subpart D—Private Contracts (§§ 405.400–405.415).The regulatory definitions of opt-out and private contract, the 10-day affidavit filing deadline for a nonparticipating physician or practitioner and the calendar-quarter route with a 30-day filing lead for a participating physician, the two-year opt-out period running from the affidavit's signing date, the delayed start when the affidavit is filed late together with the standard-rules treatment of care furnished before that filing, and the rule that a defective contract or a failure to remain in compliance voids both the private contract and the opt-out so the encounter reverts to standard Medicare rules..

The failure mode is quiet. Nothing bounces at the desk on the day; the problem surfaces months later, when somebody asks to see the affidavit and its date.

Who is allowed to opt out

Eligibility to opt out is limited to individual clinician types, and contractor guidance publishes two lists. The eligible one names MDs and DOs, podiatrists, optometrists, and dentists including the dental specialties; and among non-physician practitioners, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, clinical psychologists, clinical social workers, registered dietitians or nutrition professionals, mental health counselors, and marriage and family therapists 4Ref 4Noridian Healthcare Solutions (CMS Medicare Administrative Contractor, Jurisdiction E Part B) (2026).Who May Opt Out of Medicare - JE Part B.The two published lists of individual clinician types: the physicians and non-physician practitioners eligible to opt out, and the types that are not eligible, together with the statement that clinics, groups and other organizations cannot opt out at all..

The second list is the one that ends the question early. Chiropractors, physical therapists, occupational therapists, speech-language pathologists, qualified audiologists, anesthesiologist assistants and Part A enrolled providers and suppliers may not opt out, and clinics, groups and other organizations cannot opt out at all 4Ref 4Noridian Healthcare Solutions (CMS Medicare Administrative Contractor, Jurisdiction E Part B) (2026).Who May Opt Out of Medicare - JE Part B.The two published lists of individual clinician types: the physicians and non-physician practitioners eligible to opt out, and the types that are not eligible, together with the statement that clinics, groups and other organizations cannot opt out at all..

For a solo owner that has a structural consequence. A professional corporation cannot make this election on its own behalf. The clinician makes it personally, which means it travels with the person rather than with the business entity 4Ref 4Noridian Healthcare Solutions (CMS Medicare Administrative Contractor, Jurisdiction E Part B) (2026).Who May Opt Out of Medicare - JE Part B.The two published lists of individual clinician types: the physicians and non-physician practitioners eligible to opt out, and the types that are not eligible, together with the statement that clinics, groups and other organizations cannot opt out at all..

A clinician whose panel is already full of Medicare patients is answering a different question from the one on this page, and opting out mid-career is its own calculation.

What the private contract has to say

The contract's contents are set by regulation. It has to be in writing, in print large enough for the beneficiary to read, and among its required statements is the clause that lets a visit be priced as cash at all: that Medicare's limits do not apply to what the clinician may charge 5Ref 5Noridian Healthcare Solutions (CMS Medicare Administrative Contractor, Jurisdiction E Part B) (2026).Private Contracts with Medicare Beneficiaries - JE Part B.What a Medicare private contract must be and must state: in writing and in print large enough for the beneficiary to read it, the required statement that Medicare charge limits do not apply, the beneficiary's acceptance of full financial responsibility and agreement not to submit a claim, the prohibition on entering the contract while the beneficiary requires emergency or urgent care services, the requirement to provide it to the beneficiary before items or services are furnished, the duty to retain the signed contract and produce it on request, and the point that privately contracting is a distinct disclosed act rather than something a retainer agreement accomplishes by implication.. The same document has the beneficiary accept full financial responsibility and agree not to submit a claim, or ask you to submit one, for the contracted service 5Ref 5Noridian Healthcare Solutions (CMS Medicare Administrative Contractor, Jurisdiction E Part B) (2026).Private Contracts with Medicare Beneficiaries - JE Part B.What a Medicare private contract must be and must state: in writing and in print large enough for the beneficiary to read it, the required statement that Medicare charge limits do not apply, the beneficiary's acceptance of full financial responsibility and agreement not to submit a claim, the prohibition on entering the contract while the beneficiary requires emergency or urgent care services, the requirement to provide it to the beneficiary before items or services are furnished, the duty to retain the signed contract and produce it on request, and the point that privately contracting is a distinct disclosed act rather than something a retainer agreement accomplishes by implication..

Keep the signed contract for the full two-year opt-out period and produce it to CMS on request 5Ref 5Noridian Healthcare Solutions (CMS Medicare Administrative Contractor, Jurisdiction E Part B) (2026).Private Contracts with Medicare Beneficiaries - JE Part B.What a Medicare private contract must be and must state: in writing and in print large enough for the beneficiary to read it, the required statement that Medicare charge limits do not apply, the beneficiary's acceptance of full financial responsibility and agreement not to submit a claim, the prohibition on entering the contract while the beneficiary requires emergency or urgent care services, the requirement to provide it to the beneficiary before items or services are furnished, the duty to retain the signed contract and produce it on request, and the point that privately contracting is a distinct disclosed act rather than something a retainer agreement accomplishes by implication.. That retention duty is the practical reason it belongs with the record of care rather than in a drawer of intake forms.

A retainer or membership agreement does not do this job by implication. Privately contracting around Medicare's coverage of a service is a distinct, disclosed act with required contents 5Ref 5Noridian Healthcare Solutions (CMS Medicare Administrative Contractor, Jurisdiction E Part B) (2026).Private Contracts with Medicare Beneficiaries - JE Part B.What a Medicare private contract must be and must state: in writing and in print large enough for the beneficiary to read it, the required statement that Medicare charge limits do not apply, the beneficiary's acceptance of full financial responsibility and agreement not to submit a claim, the prohibition on entering the contract while the beneficiary requires emergency or urgent care services, the requirement to provide it to the beneficiary before items or services are furnished, the duty to retain the signed contract and produce it on request, and the point that privately contracting is a distinct disclosed act rather than something a retainer agreement accomplishes by implication., and a monthly fee that mentions insurance in passing is not that act. Practices building a hybrid membership tier tend to hit this first.

State law can add requirements on top of these federal ones. Check your state's rules before you set a cash price.

The never-enrolled question the guidance does not settle

Here is where the public guidance stops. The opt-out rules are written for clinicians Medicare already holds a record of, and none of the federal material behind this page resolves whether a clinician who has never enrolled can file a valid opt-out affidavit without first creating an enrollment record. Put that question to your MAC's provider enrollment unit in writing, before the first cash visit, and keep the answer with the affidavit.

The arrangement the caller is proposing matches neither the enrolled-and-billing position nor the opted-out-and-privately-contracting one. Collecting cash for a covered service and filing nothing is what section 1848(g)(4) is written against 1Ref 1Noridian Healthcare Solutions (CMS Medicare Administrative Contractor, Jurisdiction E Part B) (2025).Mandatory Claim Submission - JE Part B.The Social Security Act section 1848(g)(4) duty on all physicians and suppliers to submit a claim for every covered service furnished to a Medicare beneficiary regardless of assignment, and the civil monetary penalty of up to $2,000 per violation or program exclusion for failing to do so..

Status is checkable from outside, too. CMS publishes an Opt Out Affidavits list of practitioners with an approved opt-out affidavit on file 6Ref 6Centers for Medicare & Medicaid Services (2026).Opt Out Affidavits.The existence and name of the public CMS Opt Out Affidavits list of practitioners with an approved opt-out affidavit on file, as the reference point an outside office can check.. A referring office or a patient's family can look there, and an absent record leaves the question open.

The emergency you would not be able to bill

Staying outside enrollment carries a consequence that surfaces only on a bad day. A properly opted-out clinician may still submit a Medicare claim for emergency or urgent care furnished to a beneficiary with whom no private contract exists. But billing Medicare for that claim requires the clinician to be enrolled, and the contractor's instruction is to submit an enrollment application through PECOS or a paper CMS-855I, then the claims once the PTAN issues 7Ref 7Noridian Healthcare Solutions (CMS Medicare Administrative Contractor, Jurisdiction E Part B) (2026).Ordering, Referring, and Emergency or Urgent Care Services - JE Part B.The rule that an opted-out clinician may submit a Medicare claim for emergency or urgent care furnished to a beneficiary with whom no private contract exists, that billing Medicare for that claim requires the clinician to be enrolled, and the contractor's instruction to submit an enrollment application through PECOS or a paper CMS-855I and then to submit claims for emergency or urgent care once the PTAN issues..

The timing is the problem. That enrollment step has not been taken when the patient is in front of you, and the carve-out is written for exactly the beneficiary you hold no private contract with 7Ref 7Noridian Healthcare Solutions (CMS Medicare Administrative Contractor, Jurisdiction E Part B) (2026).Ordering, Referring, and Emergency or Urgent Care Services - JE Part B.The rule that an opted-out clinician may submit a Medicare claim for emergency or urgent care furnished to a beneficiary with whom no private contract exists, that billing Medicare for that claim requires the clinician to be enrolled, and the contractor's instruction to submit an enrollment application through PECOS or a paper CMS-855I and then to submit claims for emergency or urgent care once the PTAN issues..

The private contract cannot fill the gap in the moment either. It may not be entered into while the beneficiary requires emergency or urgent care services, and a copy has to be provided to the beneficiary before the items or services are furnished 5Ref 5Noridian Healthcare Solutions (CMS Medicare Administrative Contractor, Jurisdiction E Part B) (2026).Private Contracts with Medicare Beneficiaries - JE Part B.What a Medicare private contract must be and must state: in writing and in print large enough for the beneficiary to read it, the required statement that Medicare charge limits do not apply, the beneficiary's acceptance of full financial responsibility and agreement not to submit a claim, the prohibition on entering the contract while the beneficiary requires emergency or urgent care services, the requirement to provide it to the beneficiary before items or services are furnished, the duty to retain the signed contract and produce it on request, and the point that privately contracting is a distinct disclosed act rather than something a retainer agreement accomplishes by implication..

How much that matters depends on how much unscheduled work the practice expects to see, which is a question worth answering before the first affidavit is signed.

The two-year decision underneath one phone call

The caller is asking about one appointment. The election underneath it runs two years and renews on its own unless it is cancelled on time 3Ref 3Noridian Healthcare Solutions (CMS Medicare Administrative Contractor, Jurisdiction E Part B) (2026).Opt-Out Period, Renewal, and Cancellation - JE Part B.The two-year opt-out term and its automatic renewal absent a timely cancellation, which is what makes opt-out a standing status rather than a per-visit choice., so the decision in front of you is about the practice rather than the visit. Pricing then has to come from what the practice costs to run, with patient value first, ad budget second.

The other half of the arithmetic is what leaves. The subtraction list is the insurance apparatus itself: the clearinghouse, the eligibility check before every visit, the denial queue, the days a payment spends in accounts receivable, and the staff hours all of it consumes. A cash practice carries none of that, so what the dashboard measures has to be rebuilt out of the practice's own numbers.

The caller still needs something this week: a status with a filing date on it, a contract carrying the required clause, and a written response from the enrollment unit about what a clinician with no record may file.