At the end of last year, I made the decision to become a non participating provider with Medicare.

Many of my patients have questioned me about what it means to be a Medicare nonparticipating provider and what this change means for them. Some have been given misinformation by other people. Let me try to clarify.

In short, what it means is that the patient will pay for my services at the time that I see them and wait for reimbursement by Medicare.

How Does This Work?

When a physician begins practicing medicine, he or she has three options for how to interact with Medicare: participating provider, non-participating provider, or opted out provider.

Participating Provider

A participating provider is a physician who has, for lack of a better word, a Medicare contract and who accepts assignment for Medicare patients. When a physician accepts assignment, the physician agrees not to charge the patient for her services on the day of the service, but to wait 30 to 60 days for Medicare to pay her. This provider will receive 100% of the Medicare allowed amount for services that are deemed medically necessary.

Non-Participating Provider

A non-participating provider is a physician who has a “contract” with Medicare, but has chosen not to participate. When a physician chooses not to participate, he is giving himself the option to charge more for Medicare services. If this physician accepts assignment of benefits, in other words, if he agrees to be reimbursed by Medicare, he will receive only 95% of the Medicare allowable amount. If however, the physician does not accept assignment, but receives payment from the patient at the time of service, he may bill up to the limiting charge, which works out to be 109% of the Medicare allowable amount. A non participating physician, just like a participating physician must submit the claims to Medicare. If the physician doesn’t accept assignment, Medicare will reimburse the patient within thirty to sixty days.

Opted-Out Provider

An opted out provider is a physician who is not contracted with Medicare. When a physician chooses to opt out of Medicare, he or she can never submit claims to Medicare and can never be reimbursed by Medicare. If a Medicare patient wants to see an opted out physician, the doctor and patient must enter into a contract which details that neither the physician or the patient can ever receive reimbursement from Medicare.

Why Be Non-Participating?

I am a solo practitioner. Running a medical practice is expensive. Currently I wait for thirty to sixty days to get reimbursed for all of my patients, not just the Medicare ones. Insurance companies sometimes come back and recoup for services that occurred as much as four years ago on the grounds that they made a mistake and the patient for whom they paid wasn’t covered. For over two years my Medicare panel has been closed. Becoming a non-participating provider allowed me both to open my Medicare panel and continue to see my Medicare patients. If you have any questions, please call. This small change allows me to focus more on my patients.

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