325 East Sonterra Blvd.

Clinic: Suite 120

Administrative Office: Suite 220

San Antonio, TX 78258

Phone: (210) 614-5100 / Fax (210) 614-5103

San Antonio Orthopaedic Specialists

Physicians's Relationships with Medicare



Opted Out



The Participating or PAR physician is, today, the most common, but also the fastest shrinking group. PAR physicians bill and collect directly from Medicare. PAR physicians are subject to all of the compliance rules, regulations, as well as reporting requirements established by the government. There were, before ObamaCare, more than 130,000 pages of regulations concerning how a physician should run their office. I don’t know if anybody has any good idea of how many pages exist today. Violation of any of these regulations can result in fines of more than $10,00 for each occurrence. Most PAR physicians have had to hire additional personnel or outside services to document compliance, avoid fines, and potentially gain some small incentives from the government. On the other side of the issue, collections are limited by the Medicare Allowable amount. This is currently subject to the SGR. Thanks to the multiple “Doc Fixes” by congress, the mandated cuts in fees have been held off for many years. The next SGR adjustment, unless held off again, will be a cut of >27%.


These doctors are allowed to charge a small amount more than the Medicare allowable. However, they collect from the patient, and the patient collects from Medicare. NON-PAR physicians are also limited in their fees. One has to be very good at collecting from the patients in order to break even compared to PAR physicians. NON-PAR physicians are subject to all of the same rules and regulations as PAR physicians. Few physicians choose this route as it is rarely worth the trouble.

Opted Out:

Opted out physicians are freed from almost all of the Medicare requirements. Neither the physician nor the patient can bill Medicare. The financial relationship remains between the patient and the physician and is a fee for service basis. The fee is set between the two and is not regulated by the government. While the PAR and NON-PAR physician must have documentation that they made every effort to collect all co-pay amounts, the Opted Out physician may, at his or her own discretion, provide discounts or free service to their patients.

All ancillary services ordered by the opted out physician at facilities that accept Medicare are paid in their normal manner by Medicare. The percentage of opted out physicians in the state of Texas is growing about 4% per year over the last several years.

The only rules and regulations to which an Opted Out physician is subject are those required to protect the ancillary services required by patients. Two quick examples, one is reasonable, the other no so. For the hospital to be paid by medicare, the hospital must document and report compliance with many rules relative to the hospital stay. Peri-operative antibiotics is one such reasonable regulation. On the other hand, there are requirements for the documentation of failure of non operative treatment prior to elective surgery that increase the overall cost of treatment and potentially limit outcomes. Many of these requirements also apply to all patients of Medicare age whether Medicare is their primary insurance or it is not.


Dis-Enrolled physicians have no relationship whatsoever with Medicare. The patient of the Dis-Enrolled physician pays fee for service not only for the care of the physician, but also for any and all ancillary services ordered by the Dis-Enrolled physician. I know of only a very few Dis-Enrolled physicians. It is interesting to note though, that these physicians work at a charity clinic where, free of all government requirements, they are able to provide high quality and very cost effective care.