Medicare Participation—Do Physicians Have Options?

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Physicians have three contractual options when it comes to the Medicare program: participating, non-participating and opting out. Providers should keep the old saying “look before you leap” at the forefront when considering opting in or out of the Medicare program. Since 2001, physician costs have been on the rise, with only mini­mal increases in reimbursements, which makes it important for providers to be fully informed of Medicare’s guidelines.

Participating Provider (Opting In)

When a physician agrees to participate in Medicare, he or she agrees to accept Medicare’s reimbursement rates as payment in full for claims furnished during each calendar year. To become a participating provider with Medicare, individual providers and organizations, such as medical groups, may enter into a participating physician or supplier agreement with the Contractor in their state. These participation agreements can be at the individual level, between the provider and Medicare, or at an organizational level, which is between a group practice and Medicare.

A new provider can become a Medicare participant by completing the participation agreement (CMS-460) and submitting it with their Medicare enrollment application. The participation agreement will become effective on the date of filing and remains in effect through Dec. 31 following the date the agreement becomes effective, and is required to be renewed automatically for each 12-month period thereafter.

All Medicare Administrative Contractors (MACs) have the Medicare participation agreement available on their websites, with detailed instructions for providers and organizations. Keep in mind, the MACs generally send letters to providers and/or organizations in mid-November informing them of the upcoming calendar year’s payment rates and offer the opportunity to change their participation status.

Non-Participating Provider

If a provider chooses not to participate in Medicare, he or she has the option to accept assignment on a claim-by-claim basis with their MAC. If the non-participating provider accepts assignment, Medicare will reimburse claims at only 95% of the participating amount, with 80% coming from the MAC and 20% from the patient. If the non-

participating provider makes the decision not to accept assignment, he or she must complete a beneficiary’s claim form and submit it directly to Medicare. Medicare will pay the patient directly, leaving the physician to bill and collect any remaining balance for services rendered from the patient. It is not permissible for practices to charge Medicare patients for filing their claims, but by not accepting assignment, non-participating physicians can balance bill patients up to the limiting charge.