General Surgery Coding Alert

“The nonparticipating provider may receive reimbursement for rendered services directly from their Medicare patients. They submit a bill to Medicare so the beneficiary may be reimbursed for the portion of the charges for which Medicare is responsible,” Part B Medicare Administrative Contractor (MAC) Noridian Healthcare Solutions explains on its webpage.

Myth 2: Participation Means Serving All Patients

When you agree to be a participating Medicare provider, you “voluntarily and in advance enter into an agreement in writing to provide all covered services for all Medicare Part B beneficiaries on an assigned basis,” advises Part B carrier Novitas Solutions in online guidance.

“Physicians who are ‘participating’ (PAR) agree to accept Medicare’s allowed charge as payment in full for all of their Medicare patients,” expounds Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “[But] while PAR physicians must accept assignment on all Medicare claims, Medicare participation agreements do not require physician practices to accept every Medicare patient who seeks treatment from them,” Moore says.

Difference: “Physicians may elect to be a non-PAR physician, which permits them to make assignment decisions on a case-by-case basis and to bill patients for more than the Medicare allowance (up to the limiting charge) for unassigned claims,” Moore explains.

Process: “Participating and non-participating providers must follow the mandatory claim submission laws, which means you must submit the claim for payment to Medicare,” says Patsy Schwenk of Part B MAC CGS in a “Medicare Basics” webinar.

Myth 3: Non-PAR Always Means Higher Pay

Being Non-PAR can affect physician pay in both directions — up and down.

First, take a look at how PAR payments are calculated. If you say that you want to participate, “you are agreeing to accept Medicare’s fee schedule as payment in full,” cautions Schwenk. “So if Medicare’s allowed amount is $100, Medicare will pay $80 and the patient would pay $20 coinsurance and that’s all you will collect.”

PAR pros: There are some advantages to participating with Medicare, she admits. For instance, you get the full fee schedule amount, you’re set up for automatic crossover (the MAC processes the claim and sends the information to the supplemental insurers), and you’re included in the MEDPARD directory, where patients can look for providers in their area who accept assignments. About 95 percent of providers do participate in Medicare, she continues.

Non-PAR pros: Recall that non-PAR providers may select to take assignment (agree to Medicare rates) on a case by case basis. And if not accepting assignment, non-PAR providers may charge the patient more than the Medicare rate before submitting the claim to Medicare. But there are also downsides to both of these situations.

Non-PAR cons: Although non-PAR providers may accept assignment on a claim-by-claim basis, they will receive a 5 percent reduction in the fee schedule amount. “So in my previous example where I said if the fee schedule pays $100, a non-PAR provider would be starting out at just $95 instead,” Schwenk says.

There’s more: Although non-PAR providers can charge more than the Medicare fee schedule amount, they must also contend with the limiting charge rule. “The limiting charge is the maximum amount a nonparticipating provider may legally charge a beneficiary when filing an unassigned claim,” Part B MAC First Coast Service Options notes in online guidance. “The limiting charge for a service is 115 percent of the nonpar amount.”

Don’t miss: Non-compliance with the Medicare limiting charge rule carries civil monetary penalties (CMPs) up to $10,000 per violation.