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Deadline approaching for changing Medicare participation/non-participation status

David Twiddy
December 1, 2015

Physicians and other providers have until Dec. 31 to update their Medicare participation status for 2016. They have three options – participation, non-participation, and opting out – and the decision to elect participation or non-participation is binding throughout the calendar year.

Participating providers agree to accept all Medicare assignments and Medicare’s approved reimbursement amounts. Medicare pays 100 percent of the approved Medicare rate, with 80 percent of the payment coming directly from Medicare and the remaining 20 percent coming from the patient or the patient’s supplemental insurance. Participating physicians are not allowed to bill the patient directly. Medicare Administrative Contractors (MACs) process participating providers’ claims more quickly than those of non-participating providers.

Non-participating providers may accept Medicare assignments on a claim-by-claim or patient-by-patient basis. In return, they receive 95 percent of the Medicare-approved rates for participating physicians, although they can charge more than the Medicare-approved amount for unassigned claims. The maximum charge allowed for unassigned claims, or “limiting charge,” is 115 percent of the Medicare-approved amount for non-participating providers.

Providers who opt out of Medicare enter into private contracts with Medicare beneficiaries and can bill the patients directly. Once a provider has opted out, he or she cannot submit claims to Medicare for two years. Providers may choose to opt out at the beginning of any calendar quarter by submitting an opt-out affidavit to his or her MAC within 30 days of the beginning of the selected quarter. It is important to note that opting out is specific to the provider. A physician who opts out and changes practices will still not be able to submit claims to Medicare until the two-year opt-out period has expired.

To find out your participation status, you can search the Medicare Provider List. For questions regarding Medicare participation, contact your MAC. More information on Medicare is available on the AAFP website.

– Erin Solis, Regulatory Compliance Strategist for the American Academy of Family Physicians

Posted on Dec 01, 2015 by David Twiddy

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