Medicare Compliance & Reimbursement

Practices that decide to become non-PAR providers in the Medicare program often think that once they hit non-PAR status, that they’ll never have to be in contact with a Medicare representative again. But that’s not the case.

Step 1: Know What ‘Participating’ Means

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 Medicare Administrative Contractor (MAC) 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. “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.”

“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.

Step 2: Figure Out If Non-PAR Is Right for Your Practice

Going non-participating — or non-PAR for short — is different from completely opting out of Medicare altogether. Non-PAR providers can still see Medicare patients, but they aren’t considered “participating physicians.”

A non-PAR provider is still part of the Medicare program and is enrolled as a Medicare provider; however, they opt to receive payment for their services differently than a PAR provider.

“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 MAC Noridian Healthcare Solutions explains on its webpage.

Step 3: Understand Non-PAR Payment Fundamentals

If you decide to go the non-PAR provider route, that doesn’t mean you’re barred from billing the Medicare program because you chose not to participate.

PAR basics: 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 Patsy Schwenk of Medicare Administrative Contractor (MAC) CGS in a “Medicare Basics” webinar. “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.”

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 particulars: However, you can choose to be a non-PAR provider and not participate. If you are a non-par provider, you can still see Medicare patients and you still need to send in the Medicare claims on the patient’s behalf.

“Participating and non-participating providers must follow the mandatory claim submission laws, which means you must submit the claim for payment to Medicare,” Shwenk notes. If you are a non-PAR provider, you can accept assignment on a claim-by-claim basis, but non-PAR providers do 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,” she says.

Critical: Non-PAR providers 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.”

Non-compliance with the Medicare limiting charge rule carries civil monetary penalties up to $10,000 per violation.