Participation

The Deficit Reduction Act of 1984 (Public Law 98-369) established a participating physician/supplier program. A participating physician or supplier is one who voluntarily enters into an agreement to accept Medicare assignment for all covered services provided to all Medicare patients. A physician/supplier who chooses not to participate in Medicare may still accept assignment on all or some select Medicare claims. However, the provider will not receive the additional five percent payment since he/she is still classified as a non-participating provider.

Participation is an agreement that the provider agrees to accept assignment for all Medicare Part B services for which the participant is eligible to receive payment under the Medicare law and regulations. Under this Participation agreement, the provider may bill the beneficiary for the 20% coinsurance, the deductible (if applicable) and any service(s) not covered by Medicare Part B.

Benefits

To participate or not participate is a personal choice. To make an educated decision, a physician or supplier should carefully read and analyze the advantages and disadvantages of participation. He/she should also carefully evaluate the provider pricing fee schedule, and other fee schedules that may apply, to determine the impact this decision will have on the reimbursement amount. The Medicare carrier sends each provider fee schedule data when the enrollment period is announced, to assist in making an informed decision. Some things a provider should take into consideration when choosing to become a participating or nonparticipating provider include:

  • Am I trying to establish a new practice or enlarge an established practice?
  • Do I want (or need) to see more Medicare patients?
  • Are my patients able to pay?
  • Will I lose patients to competition if I don't participate?
  • Can I work with two fee schedules (e.g., Medicare limiting charge schedule and regular fees for non-Medicare patients)?
  • Will I realize more money in less time with fewer hassles?

The government has offered several advantages to encourage participation in the Medicare program, including:

  1. Higher Fee Schedule Amounts for Participating Physicians - The fee schedule amount is five percent higher than that for a non-participating provider.
  2. No Limit on Actual Charges - A participating physician can bill Medicare what he or she feels is a fair fee for the service rendered (but not more than he or she bills non-Medicare patients). Non-participating physicians are given limiting charges Noridian Participation Information October 2004 that cannot be exceeded when billing Medicare patients. This frequently means that non-participating physicians may use two fee schedules, one for Medicare patients (based on the limiting charges) and one for everyone else (normal fees).
  3. Medicare Directories of Participating Providers (MEDPARD) - The online directory lists the name, address, phone number, area and specialty of every physician or supplier who participates in the program.
  4. Reminders to Beneficiaries - Each Medicare Summary Notice (MSN) for unassigned claims will include a message reminding beneficiaries of the participation program and will tell them how much they could have saved if they had used a participating provider.
  5. Special Elective Surgery Notice - This notice is applicable to non-participating physicians and is not required of participating physicians.
  6. Payment Information Forwarded to Supplemental Insurers (Medigap) - Claim payment information will be forwarded to the patient's supplemental insurer for providers who participate, if the name, address, and policy number of the Medigap insurer is shown on the claim form prefaced by the word "MEDIGAP", "MG" or "MGAP". This information should be provided in Item 9a on the CMS-1500 claim form or appropriate electronic claim field. More information on Medigap is located in the 'Claim Submission' section of the billing module.
  7. Telephone Appeals and Access to Claim Information - Medicare Part B offers phone reviews of assigned claims and can provide more claim information once an assigned claim has been received in our office as compared to a non-assigned claim.

Form

To become a participating provider, fully complete the CMS 460 - Medicare Participating Physician or Supplier Agreement.

Providers reassigning their benefits to an organization do not need to submit a participation agreement. They will obtain the same participation status the organization has with Medicare Part B.

Eligibility Period

New Medicare providers/suppliers may file a participating provider agreement within 90 days after either of the following events:

  • Participant is newly licensed to practice medicine or another health care profession
  • Participant first opens offices for professional practice or other health care business in a particular carrier service area or locality (regardless of whether the participant previously had or retains offices elsewhere).

The participating provider status renews automatically for the next year unless the provider gives written notice of the intent to change participating status during the open enrollment period.

Change from a Participating to a Nonparticipating provider

There is only one time of the year where a provider can change from non par to par or from par to non par. The annual open enrollment period, which is usually 45 days in length, generally runs from mid-November through December 31.

During the open enrollment period, if par providers want to become non par, they can write a letter, preferably on office letterhead, indicating intent to voluntarily discontinue participation.

Mandatory Participation

The following must accept assignment on all claims. The Participation Agreement form is not applicable to you.

  • Ambulance Supplier
  • Anesthesiologist Assistant (AA)
  • Certified Nurse Midwife (CNM)
  • Certified Registered Nurse Anesthetist (CRNA)
  • Clinical Nurse Specialist (CNS)
  • Clinical Psychologist (CP)
  • Clinical Social Worker (CSW)
  • Mass Immunization Roster Biller (Flu Rosters)
  • Medical Nutrition Therapists (Registered Dietician/Nutrition Professional)
  • Medicare Diabetes Prevention Program (MDPP)
  • Nurse Practitioner (NP)
  • Physician Assistant (PA)

 

Last Updated Oct 19, 2018