How do providers bill medicare

Even for those providers steeped in Medicare law and lore, and especially for most physicians who are primarily focused on treating patients, a review of Medicare requirements can be helpfully refreshing and perhaps downright instructive.

This brief article is intended to do just that; refresh our memories, clear up a few enduring misconceptions and review some reimbursement options and consequences. This is not the same as opting out of Medicare.

Given the lack of equality in reimbursement under Medicare, certain providers, such as chiropractors, may choose this alternative. As an example, chiropractors are included within the definition of physician under the Medicare statute, as provided in section s of the Social Security Act the Act. However, the nature of services for which a chiropractor is considered to be a physician and for which there is a covered benefit is restricted to chiropractic manipulative therapy to the spine CMT provided to correct a subluxation.

Medical doctors — but not chiropractors — may also opt out of Medicare. Private rates are whatever the patient and doctor agree to for the service rendered, irrespective of the reimbursement rate set by Medicare, and no claims need, or can, be submitted to Medicare. There are still some federal requirements that have to be followed, but opting out is basically choosing to give up Medicare reimbursement in exchange for the right to charge patients your private rates.

In any event, the ability to opt out is a right available for medical doctors, not for doctors of chiropractic. Enrolled providers those who either have not opted out or cannot opt out , including chiropractors, do have the choice to either participate or be nonparticipating with respect to assignment of reimbursement of Medicare claims. Medicare rules provide that upon submission of the CMS , payment may be made either to the beneficiary or directly to the provider pursuant to an assignment agreement with Medicare.

When a provider agrees to participate in the Medicare program, the provider is agreeing to accept assignment. Nonparticipating providers are those who have elected not to accept assignment and have not signed a participation agreement with Medicare. Nonparticipating providers collect payment directly from the Medicare beneficiary, but are nonetheless limited in the amount that they can charge for Medicare-covered services. Participating providers receive percent of the Medicare Allowed Amount directly from Medicare.

In contrast, nonparticipating providers are permitted to bill the beneficiary up to the limiting charge amount, which is percent of the Allowed Amount for participating providers, who are paid 95 percent of the participating provider fee schedule amount. However, all such claims will be subject to the 5 percent reduction of the participating provider fee schedule amount.

Therefore, a non-par provider may: 1 accept assignment on a case-by-case basis, in which case the provider must accept the 80 percent of fee schedule amount as payment and collect copays from the beneficiary; or 2 not accept assignment with regard to any beneficiary or any procedure provided on a given day, and require the Medicare beneficiary to pay for the covered service up front, in which case the provider will be subject to the limiting charge amount for his or her services.

The provider may not fragment bills by accepting assignment for some services and requesting payment from the beneficiary for other services performed for that same beneficiary at the same place on the same occasion. CMS Pub. Remember, all Medicare-covered services must be billed by the provider to Medicare using the CMS , regardless of whether the provider is participating or nonparticipating in the program.

To ensure program integrity and contain costs, Congress has legislated a number of statutory exclusions from services otherwise covered. For example, Medicare covers chiropractice services for manual manipulation of the spine when medically necessary to correct a subluxation of the spine. The limiting charge rules do not apply to durable medical equipment DME suppliers.

Be sure to learn about the different rules that apply when receiving services from a DME supplier. Opt-out providers do not accept Medicare at all and have signed an agreement to be excluded from the Medicare program. This means they can charge whatever they want for services but must follow certain rules to do so. Medicare will not pay for care you receive from an opt-out provider except in emergencies. You are responsible for the entire cost of your care.

The provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not reimburse you. Opt-out providers do not bill Medicare for services you receive. Many psychiatrists opt out of Medicare.

Provisions in the Balanced Budget Act of give physicians and their Medicare patients the freedom to privately contract to provide health care services outside the Medicare system. Private contracting decisions may not be made on a case-by-case or patient-by-patient basis, however. Once physicians have opted out of Medicare, they cannot submit claims to Medicare for any of their patients for a two-year period.

A physician who has not been excluded under sections , or of the Social Security Act may, however, order, certify the need for, or refer a beneficiary for Medicare-covered items and services, provided the physician is not paid, directly or indirectly, for such services except for emergency and urgent care services. For example, if a physician who has opted out of Medicare refers a beneficiary for medically necessary services, such as laboratory, DMEPOS or inpatient hospitalization, those services would be covered by Medicare.

To privately contract with a Medicare beneficiary, a physician must enter into a private contract that meets specific requirements, as set forth in the sample private contract below. In addition to the private contract, the physician must also file an affidavit that meets certain requirements, as contained in the sample affidavit below. To opt out, a physician must file an affidavit that meets the necessary criteria and is received by the MAC at least 30 days before the first day of the next calendar quarter.

There is a day period after the effective date of the first opt-out affidavit during which physicians may revoke the opt-out and return to Medicare as if they had never opted out. Physicians who have opted-out of Medicare under the Medicare private contract provisions may furnish emergency care services or urgent care services to a Medicare beneficiary with whom the physician has previously entered into a private contract so long as the physician and beneficiary entered into the private contract before the onset of the emergency medical condition or urgent medical condition.

These services would be furnished under the terms of the private contract. Physicians who have opted-out of Medicare under the Medicare private contract provisions may continue to furnish emergency or urgent care services to a Medicare beneficiary with whom the physician has not previously entered into a private contract, provided the physician:. Note that a physician who has been excluded from Medicare must comply with Medicare regulations relating to scope and effect of the exclusion 42 C.

The sample private contract and affidavit below contain the provisions that Medicare requires unless otherwise noted to be included in these documents. In addition, the contract must state unambiguously that by signing the private contract, the beneficiary:. If you determine that you want to "opt out" of Medicare under a private contract, we recommend that you consult with your attorney to develop a valid contract containing other standard non-Medicare required provisions that generally are included in any standard contract.

Read More. The Three Options There are basically three Medicare contractual options for physicians. Directories of PAR physicians are provided to senior citizen groups and individuals who request them.

Medicare administrative contractors MAC provide toll-free claims processing lines to PAR physicians and process their claims more quickly.

Private Contracting Provisions in the Balanced Budget Act of give physicians and their Medicare patients the freedom to privately contract to provide health care services outside the Medicare system.

Emergency and Urgent Care Services Furnished During the "Opt-Out" Period Physicians who have opted-out of Medicare under the Medicare private contract provisions may furnish emergency care services or urgent care services to a Medicare beneficiary with whom the physician has previously entered into a private contract so long as the physician and beneficiary entered into the private contract before the onset of the emergency medical condition or urgent medical condition.

Physicians who have opted-out of Medicare under the Medicare private contract provisions may continue to furnish emergency or urgent care services to a Medicare beneficiary with whom the physician has not previously entered into a private contract, provided the physician: Submits a claim to Medicare in accordance with both 42 CFR part relating to conditions for Medicare payment and Medicare instructions including but not limited to complying with proper coding of emergency or urgent care services furnished by physicians and qualified health care professionals who have opted-out of Medicare.

Collects no more than the Medicare limiting charge, in the case of a physician or the deductible and coinsurance, in the case of a qualified health care professional.