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Ask-A-Consultant: Advantages/Disadvantages as a Medicare participating provider vs. a non-participating provider


What are the advantages/disadvantages to being either a Medicare participating provider vs. a non-participating provider?


Physicians who are participating providers with Medicare receive the benefit of being listed in the Medicare's Participating Physician's Directory; can collect up to the Medicare allowed fee on assigned claims (not reduced by 5% as they are for non par providers; are provided automatic crossover of Medigap claims; and have the benefit of only needing one fee schedule for their practice. The most recent report for CY 2001 indicated that 88.7% of all physicians, practioners and suppliers were Medicare participating providers.

Non Par providers may benefit from the ability to collect up to the Limiting Charge which is 9.25% above the Medicare Participating Allowed fee when a claim is filed without accepting assignment. However, the allowed fee for assigned claims is 5% less than that for participating providers. Non Participating physicians must maintain two fee schedules; a standard fee schedule for their Non-Medicare patients and a fee schedule of Limiting Charges for Medicare patients (115% of the Non Par Allowable which is 95% of the Par Allowable).

Psychiatrists may benefit from non participation if they are able to collect their Limiting Charge at the time services are provided. In that way they can bill and collect fees that are 9.25% higher than if they were participating, without the risk of the patient not paying the bill. However, the provider should consider the percent of services they provide when it is not practical for the patient to pay at the time of service (i.e. inpatient care) and the risk of not being paid if the claim is filed as non assigned and the payment goes to the patient or if payment is guaranteed through accepting assignment but the amount of payment is reduced (i.e. the difference in the Limiting Charge and the Non Par Allowed Fee).

Russ 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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Medical Management Associates, Inc.
3330 Cumberland Boulevard Suite 200 Atlanta, GA 30339
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