Medicare Chiropractic Provider Vs. Non Provider

Medicare Participating vs. Non-Participating Provider

Question: Dr Kotlar, “I just received my NPI number and want to start seeing Medicare patients. I have to make a decision at this point to become a participating provider or non-participating provider within the Medicare program. What do you recommend?

 Answer: I will supply you with the differences between a participating provider and non-participating provider and then I’ll let you decide what’s best for your particular situation. But before I begin, I must inform you that par and non-par providers must follow the same rules and regulations as it pertains to proper and compliant documentation. For example, Medicare par and non-par providers need to establish the existence of spinal subluxation through the P.A.R.T. exam or x-rays, understand the AT, GA, GY & GZ modifiers, create treatment plans with specific treatment goals, choose compliant CPT/ICD codes, know when and how to incorporate the ABN form and know how to document the initial and subsequent visits properly.

Medicare participating providers must adhere to the following:

Medicare participating providers must adhere to the following:

  • 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.
  • Agrees to accept Medicare approved amount as payment in full.
  • May not collect more than applicable deductible and coinsurance for covered services from patient. Payment for non-covered services may also be collected.
  • Charges are not subject to the limiting charge.
  • Medicare payment paid directly to the provider.
  • Mandatory claims submission applies.
  • Reimbursement is 5 percent higher than the non-participating amount.
  • Secondary/supplemental information is transferred.

Medicare non-participating providers must adhere to the following:

  • A non-participating provider has not entered into an agreement to accept assignment on all Medicare claims.
  • Can elect to accept assignment or not accept assignment on a claim-by-claim basis.
  • Cannot bill the patient more than the limiting charge on non-assigned claims.
  • Patient receives payment on non-assigned claims.
  • Mandatory claims submission applies.
  • Approved amount is 5 percent less than participating – even if assignment is accepted on the claim.

 

Below is a sample Medicare fee schedule for CPT code 98940 and 3 possible financial arrangements:

Your Regular Fee: $35.00

Par Fee Allowance: $32.00

Non-Par Fee Allowance: $30.00

Limiting Charge Fee: $34.00

 

1) Participating Provider:

As a participating provider, the PFA is $32.00. Assuming the deductible has been met, the patient is responsible to pay you 20% of the PFA, which is $6.40. You bill Medicare $35.00 (your regular fee). Medicare will pay you $25.60, which is 80% of PFA ($32.00). $25.60 + $6.40 = $32.00. The difference between your regular fee and the PFA is $3.00, which needs to be written off.

2) Non-Participating Provider & Not Accepting Assignment:

As a non-participating provider and not willing to accept assignment, the patient is responsible to pay you the Limiting Charge of $34.00. You cannot accept your regular fee of $35.00 even though you are non-participating. You bill Medicare the Limiting Charge of $34.00. Medicare will reimburse the patient $24.00, which is 80% of the Non-Par Fee Allowance (assuming the deductible has been met).

3) Non-Participating Provider & Accepting Assignment:

As a non-participating provider and willing to accept assignment, the patient is responsible to pay you 20% of the Non-Par Fee Allowance ($30.00), which is $6.00. You bill Medicare $30.00. Medicare will reimburse you $24.00, which is 80% of the Non-Par Fee Allowance (assuming the deductible has been met).

Just a side note, at the present time DCs cannot “opt-out” of the Medicare program – so if you choose to treat Medicare patients, then you must follow the above rules.

Click here to read more about Dr. Marty Kotlar. The author’s opinions are their own and DC Aligned does not take responsibility for content statements and opinions. You should seek expert counsel in evaluating opinions, treatments, products and services. For more info see our Editorial Policies.

  • Camie

    The above information, does this also apply for Texas providers?

    • MeyerDC

      Thank you for your comment Camie, we encourage you to check the ChiroHealth USA website for specific coverage details available by state: https://www.chirohealthusa.com/