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If I enroll as a Medicare provider, must I submit claims to Medicare (rather than just bill the patient) and can I bill the patient the difference between my fees and the Medicare reimbursement?


Thank you for your question to Medical Management Associate’s Ask a Consultant. When enrolling as a Medicare provider, you choose one of two statuses: participating provider or non-participating provider. Each has distinct billing and reimbursement policies and procedures.

As both a participating and non-participating provider, you are required to submit claims to Medicare.

As a participating physician, you agree to accept Medicare's allowed fee as payment in full for your services. You may submit any fee you choose to Medicare (i.e., your normal fee schedule, the Medicare-allowed fee or any other fee). Medicare will pay you directly, on these assigned claims, 80% of the lower of the Medicare allowed fee OR the submitted fee. The patient must pay the 20% balance of either the Medicare allowable or the lower fee.

As a non-participating provider, you have a choice to accept or reject assignment on a claim-by-claim basis. However, as a non-participating provider you are limited in what you can charge Medicare patients by the “limiting charge.” This fee is calculated at 115% of the non-participating provider allowed fee. The non-participating allowed (“non-par”) fee is 95% of the participating fee.

If you choose not to accept assignment on a claim, you are still required to submit your claim to Medicare using the limiting charge. You may collect the limiting charge from the patient at the time of service, or later if you so choose. If you accept assignment on a non-par claim, you must submit the claim to Medicare and your fee is limited to the limiting charge. However, you must accept Medicare’s non-par allowed fee (95% of the participating allowed fee) as your fee in full. Medicare will pay you 80% of the non-par allowed fee and you collect 20% from the patient or their secondary insurance company.

Therefore, in answer to your question “can you bill the patient the difference between your fees and the Medicare reimbursement,” the answer is “yes” if you are a non-par provider and do not accept assignment on the claim. However, your fee for Medicare patients is set at the limiting charge. If you are a par provider, the answer to that question is “no.”

If we can be of further assistance, please do not hesitate to contact us.

Russell B. Still
Executive Vice President

MMA does not provide legal, accounting, or tax advice.  If you need assistance in these areas, we recommend that you consult a qualified professional.  In addition, please note that a client relationship with MMA is not established by the submission of a question to this forum or by the publishing of MMA's response.

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