How nonparticipating physicians impact your Medicare bills; Covering; The Bases

I have heard that doctors can participate with Medicare or can be nonparticipating. Someone said nonparticipating doctors must bill Medicare. Then I heard that some doctors opt-out of Medicare and cannot bill Medicare. All of this is confusing. Please help me understand what this means to me.

Most physicians are either participating or nonparticipating providers. Both participating and nonparticipating providers must bill Medicare on behalf of a Medicare patient. Medicare will make payments for approved services rendered by either a participating and nonparticipating physician. The basic difference is nonparticipating providers can bill at a higher rate than participating providers.

Participating Providers have agreed to "accept assignment" meaning they will accept the Medicare allowed amount as payment in full. When the provider provides service, the provider submits the claim to Medicare. Medicare determines what the Medicare allowed amount is for the particular service provided. Medicare notifies both the provider and the patient of the amount Medicare has approved.

After the yearly deductible is met, Medicare pays the provider 80% of the Medicare-allowed amount. The provider bills the client (or the client's secondary insurance) the remaining 20%. The combination of the 80% paid by Medicare and the 20% paid by the client (or his/her secondary insurance) is paid in full.

Non-Participating Providers can choose to either accept an assignment or not-accept assignment. If the provider accepts assignment, they bill as described above. If they choose to not accept assignment, the provider submits a non-assigned claim and the provider may charge approximately 15% above the Medicare allowed amount.

Medicare sets a threshold called a "limiting charge" for nonassigned claims. In most cases, a provider cannot bill above the limiting charge that is set by Medicare. This limiting charge helps to protect a patient from excessive charges.

Of special note for a non-assigned claim: The nonparticipating physician can bill the client, up front, at the time of service, for any amount the provider desires. Once the claim is processed by Medicare, the physician must reimburse the client for any amount the client paid above the limited charge.

The next two providers: Opt-Out and Excluded Providers do not (or cannot) bill Medicare.

Opt-Out Providers are providers who have decided they do not want to have anything to do with Medicare. These providers have filed an affidavit with Medicare stating their intent to opt-out. These providers must notify all their Medicare-eligible clients, in writing, that Medicare cannot be billed for the services rendered by this provider. The client then signs a written contract that meets the opt-out standards. The client agrees to pay the provider the amount the provider bills for services. If the client submits a claim to Medicare, the claim will be denied.

There is one exception to Medicare nonpayment of claims to an opt-out provider: If a Medicare-enrolled person presents in the Emergency Room for an emergency situation and an opt-out provider renders emergency services, then Medicare could make a payment on the claim.

Excluded Providers are barred from participating in federally-funded programs such as Medicare. These providers have been convicted of such violations as: patient abuse/neglect, felony health care fraud, felony substance abuse, etc. Many of these providers have had their medical licenses revoked.

A list of these providers is at exclusions.oig.hhs.gov.

Amy Rubino is the director of the Senior Health Insurance Assistance Program and the Senior Medicare Patrol for the Anne Arundel County Department of Aging and Disabilities. You may contact either program at 410-222-4257 or ship_program@aacounty.org.

Credit: Amy Rubino - Amy Rubino is the director of the Senior Health Insurance Assistance Program and the Senior Medicare Patrol for the Anne Arundel County Department of Aging and Disabilities. You may contact either program at 410-222-4257 or ship_program@aacounty.org.