Understand your options for Medicare enrollment
Find out what you can expect expect if you're a Medicare participating physician, Medicare non-participating physician or private contractor.
Physicians must be enrolled in Medicare in order to provide, order or refer services covered under Medicare. However, being enrolled doesn’t mean you have to participate in Medicare. There are three options for Medicare enrollment:
Medicare Participating Physician
Under this option, Medicare is billed directly for 100% of the services your patients receive; your practice then receives payment from Medicare. In areas with high populations of Medicare-age patients, participating in the program may be a smart business move, since you risk losing patients to other providers if you don’t.
Medicare Non-Participating Physician
Medicare non-participating physicians can still see Medicare patients. In this case, patients pay a 20% copay, Medicare reimburses the patient the remaining 80%, and the patient then pays that 80% to the practice.
This option may seem attractive because Medicare non-participating physicians can bill 115% of the fee schedule rate. However, it’s important to weigh whether the extra revenue is worth the extra hassle you may encounter. Consider:
How good at collections is your practice?
How many patients can you stand to lose? You can reduce collections issues by requiring patients to pay the full cost of their services up front, but this puts you at risk of losing business from patients who can’t afford to pay you until they’ve been reimbursed by Medicare.
If you choose this option, it’s a good idea to be sure your practice is making an extra effort to stand out in care and customer service, since patients are taking on an extra administrative and financial burden in order to see you. Submitting insurance claims for patients is one step you can take to encourage them to choose you.
Keeping Medicare Information Current
The Centers for Medicare & Medicaid Services (CMS) requires Medicare providers and suppliers to keep their enrollment information up to date at all times. Changes in this information can affect claims processing, payment amounts and eligibility to participate in the Medicare program. Failing to report changes in information in accordance with CMS requirements has serious consequences, including costly mistakes and possible revocation of Medicare billing privileges.
To enter into a private contract with Medicare patients, you must have an opt-out affidavit on file in which patients agree not to submit any claims to Medicare for your services. You can continue to see Medicare patients, but they will be responsible for paying 100% of your fees. This option could make sense if you know you can rely on patients with private payer insurance to supply most of your practice’s business.
Since Medicare patients are footing the bill themselves, they may be more likely to research other providers’ pricing, which could include comparing your Medicare earnings with those of other physicians. These numbers can be easily misinterpreted, so it’s wise to be ready to provide context for your Medicare payment data should patients ask about it.