Wednesday, October 14, 2015

Participating vs non participating provider

Participating ProviderNon-Participating Provider
A participating provider is one who voluntarily and in advance enters into an agreement in writing to provide all covered services for all Medicare Part B beneficiaries on an assigned basis.A non-participating provider has not entered into an agreement to accept assignment on all Medicare claims.
Agrees to accept Medicare-approved amount as payment in full.Can elect to accept assignment or not accept assignment on a claim-by-claim basis.
May not collect more than applicable deductible and coinsurance for covered services from patient. Payment for non-covered services may also be collected.If the provider performs elective surgery costing more than $500, the beneficiary must be notified in writing of the expected financial responsibility.
Charges are not subject to limiting charge.Cannot bill the patient more than the limiting charge on non-assigned claims. (DC, DE, MD, NJ, City of Alexandria, VA, Counties of Arlington and Fairfax in VA)
Medicare payment paid directly to the provider.Pennsylvania’s Medicare Overcharge Measure prevents non-participating physicians from charging patients more than the Medicare allowance. Therefore, PA providers cannot bill the patient more than the Medicare approved amount on non-assigned claims.
Mandatory claims submission applies.Beneficiary receives payment on non-assigned claims.
Placement in Medicare Participating Physicians and Suppliers Directory (MEDPARD).Mandatory claims submission applies.
Reimbursement is 5 percent higher than the non-participating amount.Clinical laboratory services and drugs and biologicals must be billed as assigned.
Medigap information is transferred.Approved amount is 5 percent less than participating — even if assignment is accepted on the claim.
Patient referral service by hospital.Medigap information is not transferred.

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