A brief guide to deciding on Medicare participation
Every year from mid-November through Dec. 31, physicians can decide whether to participate in Medicare for the upcoming year.
Participation means you agree to accept claims assignment for all Medicare-covered services to your patients. You also agree to accept Medicare-allowed amounts as payment in full, and you may not collect more from the patient than the Medicare deductible and coinsurance or copayment. The following table identifies some of the differences between being a “participating” or “non-participating” physician:
Participating
- Medicare pays the full amount allowed under the Medicare Physician Fee Schedule.
- Medicare pays you directly.
- Medicare forwards claim information to Medigap (Medicare supplement coverage) insurers.
Non-participating
- Medicare pays 5% less than the amount the Medicare Physician Fee Schedule allows.
- You can’t charge the patient more than the limiting charge, which is 115% of the Medicare Physician Fee Schedule amount.
- You may accept claims assignment on a case-by-case basis.
- You have limited appeal rights.
There is a third option: private contracting with Medicare beneficiaries. The Balanced Budget Act of 1997 gave physicians and their Medicare patients the freedom to privately contract to provide health care services outside the Medicare system. You may make private contracting decisions on a case-by-case or patient-by-patient basis. However, once you have opted out of Medicare, you cannot submit claims to Medicare for any of your patients for a two-year period.
For more information, please see the Medicare Options page on the AAFP’s website or the “Annual Medicare Participation Announcement” on the Centers for Medicare & Medicaid Services’ website and the related announcement (PDF) for 2024.
— Kent Moore, AAFP Senior Manager, Payment Strategies
Posted on Nov. 17, 2023
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Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use.