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Practicing Medicine Business of Medicine Medicare Enrollment Guide Medicare Participation FAQ

Medicare Participation FAQ

Your questions answered

Frequently Asked Questions

Find answers to your questions on opting in and out of Medicare, patient billing, private contracting and the Medicare Fee Schedule.

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When can I enroll in Medicare?

Physicians can enroll in Medicare at any time.

When can I change my Medicare participation status or opt out?

You can change your participation from PAR to non-PAR or vice versa between Nov. 15 and Dec. 31 every year.

To opt out of Medicare and enter into a private contract with your patients, physicians must give Medicare 30 days’ notice before the first day of the quarter the contract takes effect. That means:

  • To opt out as of May 1, you must submit your opt-out affidavit by March 31.
  • To opt out as of Sept. 1, submit your opt-out affidavit by August 1.
  • To opt out as of Jan. 1, submit your opt-out affidavit by Dec. 1.
What is the maximum I can charge a Medicare patient if I am non-participating?

The non-PAR physician is allowed to bill the patient a limiting charge of no more than 115% of the Medicare Fee Schedule.

May I order or refer if I am a Medicare non-participating physician?

Yes, because even though you’re a non-participating physician, you are still enrolled in Medicare.

In addition, you may enroll as a Medicare non-PAR ordering/referring physician only. In that case, you don’t treat Medicare beneficiaries, but you may be allowed to write and order for Medicare patients or refer them for treatment.

If you don’t enroll in Medicare as a non-participating physician, any services ordered or referred for treatment will not be paid and claims will be denied. Learn about ordering and referring denial edits.

If I opt out of Medicare and enter into a private contract, can I still order or refer services?

Yes, but you have to have an opt-out affidavit on file with your Medicare Administrative Contractor. Here’s what’s required:

  • The physician must sign an affidavit agreeing not to treat Medicare patients without a private right to contract for a required minimum of two years.

  • You must continue to opt out every two years in order to remain opted out. Failure to remain opted out could result in fines and penalties.

  • The private right to contract should be signed by the patient agreeing that they will not submit any claims to Medicare for your services.

Where can I find the Medicare Fee Schedule?

Please note that the Medicare Fee Schedule is subject to the 2% annual sequestration reduction as required under the Budget Control Act. View the Physician Fee Schedule search tool.

At my practice, I'm a Medicare participating physician. I also work at a clinic that treats Medicare patients on a cash-only basis. At the cash-only clinic, may I bill the Medicare patients above the limiting charge?

No. Your Medicare participation is linked with your NPI number, so your participation status is the same wherever you practice. You would be violating your Medicare agreement to accept assignment, and you also risk that the patient may be submitting the bill for some reimbursement.

In order to charge above the limiting charge, you have to be opted out of Medicare and have a private right to contract signed by the patient.

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