Dan, I am a doctor and do my own billing.
But first I want to talk about your medicare premiums. Although I'm not on medicare, my parents are, and obviously pay premiums. Obviously yours and my parents premiums go to help pay for medicare benefits. But, at the same time, medicare is also heavily subsidized by the working class. Ever note that Medicare tax on your W2's. Although I haven't seen the breakdown, I bet the majority of Medicare funds come from the working class, not the premiums from medicare enrollees. I can't remember the exact figure, but I think medicare pays these insurance companies about 3X your monthly medicare premium to take "acceptable" care of you; what they believe is acceptable and what medicare believes is acceptabel may be two different things. These insurance companies entice you with prescription benefits, lower deductables, whatever, to join their program and give up basic medicare, as they think they can make a profit by having doctors like myself accept lower rates than medicare. For a while, they were picking and chosing which medicare enrollees were the healthiest, since they knew those healthier enrollee's wouldn't cost them alot of money. Believe me, it's a money maker for Aetna, Kaiser, BC/BS, etc.
I do accept medicare assignment, and I am a participating provider. But, I can tell you, when you first sign up for medicare, as a provider, you have an option of whether you want to sign up as a "participating" provider, or a non-participating" provider. If you sign up as a participating provider, you agree to accept the standard Medicare rates, and the money is sent to me, the provider. As a non-participating provider, I still participate with medicare, and I agree to the medicare 15% higher rate limits, but the patient will be responsible for more of the percentage, and medicare instead sends the payment to the enrollee, meaning I, as the doctor, would need to have the medicare enrollee pay me up front for the 15% higher allowed amount, bill medicare, and then medicare will then reimburse the patient for their portion. So even if a provider is a" non-participating", he still is participating to a different degree. Dan, I have realized from your posts that you have a wealth of information. Believe me, I run my practice like a business now, and at one point had thought about changing my status to non-participating, but that's going to turn off patients badly, overall hurting my business as well as collecting money. That's why very few doctor's are non-participating. Believe me, I didn;t learn anything about this in med school or residency.
here's a good explanation. Although it talks about audiologists, the same is true for doctors.
http://www.audiologyonline.com/askex...uestion_id=523
What is the difference between participating and non-participating providers for Medicare? What are the options for audiologists in being able to participate in either manner?
Every audiologist must decide if they should participate or not with Medicare, as well as, other third party payors. Most seniors and people in general do look for providers who accept their insurance, so choosing not to participate can have devastating negative affects on a healthcare business. That said, randomly participating with all third party payors without understanding the terms of that participation including reimbursement levels and potential risks can also be devastating to an audiology business.
With Medicare, audiologists basically have three choices; participate as a “participating provider”, participate as a “non-participating provider”, or “opt-out”. One’s chosen status with Medicare will dictate who you bill, how much you collect for a given procedure, the responsible party, whether or not you must have a “private contract” with beneficiaries, and what that private contract must include to name a few things.
Although Medicare is a federally funded program, it is also administered by state or regional intermediaries who have been know to interpret Medicare (federal) policy differently. It is always wise to identify, contact, and document in writing any information that is provided to you by your intermediary.
As a general rule:
“Participating Providers” accept assignment from Medicare. The provider bills Medicare at their usual and customary fee; however, Medicare pays the provider 80% of the “allowed amount” for each CPT code. Patients are responsible for 20% of the allowed amount and this 20% should not be waived. The provider cannot bill patients for amounts in excess of the allowed amount and must write off the difference between the allowed amount and usual and customary fees.
“Non-participating Providers” do in fact participate with Medicare. Non-par providers generally do not accept assignment on a regular basis; however, can choose to accept assignment on a case-by-case basis and be reimbursed at the non-par level. Non-par providers must bill Medicare, but Medicare reimburses the patient versus the provider. The amount patients receive from Medicare will be 5% less than the par-allowed amount and the patient pays the provider for services rendered.
A non-par provider can legitimately increase reimbursement by charging the “limiting fees”, which represent the maximum allowable reimbursement. Limiting fees, as well as, par and non-par allowed fees can vary by region, state, and even city and can be found at
www.cms.gov.
“Opting-Out” If an audiologist sees Medicare beneficiaries and chooses not to participate with Medicare, they must opt-out and in many states sign an opt-out affidavit. That opt-out affidavit also includes private contract requirements. If you choose to opt-out, you cannot re-apply for Medicare participation status for two years. It is very important to understand the impact third party payor participation can have on one’s practice before committing to any level of provider status or choosing to opt-out.
Note: “Audiologists” are not specifically listed under physicians or practitioners who are eligible to contract privately; however, audiologists do meet the criteria of being “legally authorized to practice by the state and otherwise meet Medicare requirements”. Various Medicare intermediaries can interpret this differently.
Kathy Foltner, AuD, is CEO of AuDNet, Inc. She also teaches courses in Practice Management and Basic Business at Rush University Medical Center and PCO. Dr. Foltner can be reached at
kfoltner@aud-net.com or 312-593-1787.
For more information about AuDNet, visit
www.howtohear.com/ or the AuDNet Web Channel on Audiology Online