Medicare Plans Provider Participation

By | February 1, 2013

2. They don’t accept assignment. This means they can still see Medicare patients, but the claim payments are not assigned to the provider, though the provider is still required to file the claim with Medicare. In this case the provider is allowed to charge excess charges of 15% (actually 9.25% as previously noted) above the Medicare allowed charge. The provider must collect the entire fee from the patient and Medicare sends the re-imbursement to the insured. This can (and frequently does) cause a collections problem for the provider since the provider must wait for the patient to pay the bill.

3. The provider accepts Medicare assignement (over 99% of all providers that participate in Medicare accept assignment). This means the provider files the claim with Medicare and recieves the assigned payment directly from Medicare.

Most of the confurion is coming from the situation where providers simply don’t participate in Medicare. This situation is erroniously being reported as they “don’t accept assignment”, but in reality, they don’t accept Medicare at all. In our area this is becoming the bigger problem.

Here’s what happens if your doctor, provider, or supplier doesn’t accept assignment:

You might have to pay the entire charge at the time of service. Your doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare-covered services they provide to you.

They can’t charge you for submitting a claim. If they don’t submit the Medicare claim once you ask them to, call 1?800?MEDICARE.

In some cases, you might have to submit your own claim to Medicare using Form CMS-1490S to get paid back.

They can charge you more than the Medicare-approved amount, but there’s a limit called “the limiting charge.” The provider can only charge you up to 15% over the amount that non-participating providers are paid. Non-participating providers are paid 95% of the fee schedule amount.

Medicare doesn’t pay for any charges for “opt out” doc’s, just for doc’s who are “Par” and “Non-Par”.