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Participating provider versus non-participating provider

Participating provider Non-participating provider
  • A participating provider is one who voluntarily and in advance enters into an agreement in writing to provide all covered services for all Medicare Part B beneficiaries on an assigned basis
  • Agrees to accept Medicare-approved amount as payment in full
  • May not collect more than applicable deductible and coinsurance for covered services from patient. Payment for non-covered services may also be collected
  • Charges are not subject to limiting charge
  • Medicare payment paid directly to the provider
  • Mandatory claims submission applies
  • Placement in Medicare Participating Physicians and Suppliers Directory (MEDPARD)
  • Reimbursement is 5% higher than the non-participating amount
  • Medigap information is transferred
  • Patient referral service by hospital
  • A non-participating provider has not entered into an agreement to accept assignment on all Medicare claims
  • Can elect to accept assignment or not accept assignment on a claim-by-claim basis
  • Cannot bill the patient more than the limiting charge on non-assigned claims
  • Pennsylvania’s Medicare Overcharge Measure prevents non-participating physicians from charging patients more than the Medicare allowance. Therefore, PA providers cannot bill the patient more than the Medicare approved amount on non-assigned claims
  • Beneficiary receives payment on non-assigned claims
  • Mandatory claims submission applies
  • Clinical laboratory services and drugs and biologicals must be billed as assigned
  • Approved amount is 5% less than participating — even if assignment is accepted on the claim
  • Medigap information is not transferred

 

Note: Toward the end of each calendar year there is an open enrollment period. The open enrollment period is generally from mid-November through December 31. During this period, if you’re enrolled in the Medicare Program, you can change your current participation status beginning the next calendar year on January 1. This is the only time you have the opportunity to change your participation status.

New physicians, practitioners, and suppliers can sign the participation agreement and become a Medicare participant at the time of enrollment into the Medicare program. The participation agreement will become effective on the Medicare effective date.

All practitioners and suppliers eligible to receive payments under Part B of Medicare may choose to enter into a participation agreement. This includes practitioners whose services are subject to mandatory assignment as listed below. The reason why it could still be appropriate for such practitioners to enter into a participation agreement is because the mandatory assignment provisions apply only to the particular practitioner service benefit (e.g., nurse practitioner services).

Thus, for example, if a nurse practitioner is eligible to bill for, and is indeed billing under, Part B for something other than a nurse practitioner service (e.g., an EKG tracing), the mandatory assignment provision of the law does not apply to that other service. However, if the nurse practitioner has entered into a participation agreement, that agreement requires that the nurse practitioner accept assignment for any service for which he or she submits a Medicare Part B claim.

  • Physician assistant
  • Nurse practitioner
  • Certified registered nurse anesthetist
  • Clinical nurse specialist
  • Certified nurse midwife
  • Clinical social worker
  • Clinical psychologist
  • Registered dietician/nutrition professional
  • Anesthesiologist assistant
  • Marriage and family therapist
  • Mental health counselor
  • Mass immunization roster billers
  • Ambulatory surgical center

 

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