American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Medicare Enrollment and Participation

Physicians, non-physician practitioners (NPPs), and other Medicare Part B suppliers must enroll in the Medicare program to be paid for covered services furnished to Medicare beneficiaries. To assist Fellows in navigating their contractual relationships with the Centers for Medicare & Medicaid Services (CMS), this webpage answers a number of questions surgeons may have about becoming a participating Medicare provider. 

Note: Providers must make their 2018 Medicare participation determination by December 31, 2017.

Who can participate in Medicare?

The table below lists physicians, NPPs, and other suppliers who can enroll as Medicare Part B participating providers.

Provider Types Eligible for Medicare Participation

Physicians, NPPs, Suppliers

Clinics, Group Practices, Other Suppliers

Anesthesiology Assistants

Audiologists

Certified Nurse-Midwives

Certified Registered Nurse Anesthetists

Clinical Nurse Specialists

Clinical Psychologists

Clinical Social Workers

Mass Immunization Roster Billers

Nurse Practitioners

Physical/Occupation Therapists 

Physicians (Doctors of Medicine, Osteopathy, Dental Medicine, Dental Surgery, Podiatric Medicine, Optometry)

Physician Assistants

Registered Dietitians or Nutrition Professionals

Speech-Language Pathologists

Ambulance Service Suppliers

Ambulatory Surgical Centers

Clinics/Group Practices

Independent Clinical Laboratories

Independent Diagnostic Testing Facilities

Intensive Cardiac Rehabilitation Suppliers

Mammography Centers

Mass Immunization Roster Billers

Physical/Occupational Therapy Groups

Portable X-ray Suppliers

Radiation Therapy Centers

What Medicare participation options are available for surgeons?

Surgeons have three ways to participate in Medicare Part B:

  • Sign a participation (PAR) agreement. Providers who choose to participate in the Medicare program agree to provide all covered services for all Medicare beneficiaries on an assigned claims basis.
  • Elect non-participation (non-PAR). Providers who select the non-PAR option are permitted to choose to either accept or not accept Medicare assignment on claims on a case-by-case basis. Providers who do not accept Medicare assignment may bill patients for more than the Medicare-allowed amount for a particular service.
  • Become a private contracting physician (opt-out). Providers who decide to opt-out of Medicare participation must bill their patients directly and forego any Medicare reimbursement.

What does it mean to be a participating (PAR) provider?

Under the Medicare program, PAR providers are contractually obligated to accept Medicare assignment for all claims in which a covered service is furnished to a Medicare beneficiary. PAR providers are reimbursed directly by Medicare for 80 percent of a service’s Medicare Physician Fee Schedule (PFS) amount in addition to a 20 percent copayment recouped from patients or their supplementary insurance. PAR providers receive 100 percent of the Medicare allowed amount and must accept this amount as payment in full, and may not collect more than the Medicare deductible and copayment from any beneficiary.

What does it mean to be a non-participating (non-PAR) provider?

Non-participating providers may determine on an individual claim basis whether to accept Medicare assignment. For assigned claims, the total Medicare allowed amounts for services furnished by non-PAR providers are 5 percent lower compared to the allowed amounts for PAR providers. Non-PAR providers who submit assigned claims are not reimbursed directly by Medicare; instead, Medicare pays patients for 80 percent of a service’s PFS amount, and patients are then responsible for passing on the Medicare payment plus the 20 percent copayment (which may be covered by supplementary insurance) to their providers.
For unassigned claims, non-PAR providers may bill up to 115 percent of the 95 percent non-PAR Medicare PFS allowed amount (i.e., the “limiting charge”). The limiting charge is the maximum amount a non-PAR provider may legally charge a patient when filing an unassigned claim.

What should surgeons know about being a non-PAR provider?

Non-PAR surgeons who choose to forgo Medicare assignment for any non-emergent, elective procedure costing more than $500 must give written notice to Medicare beneficiaries that charges for the procedure may exceed the Medicare approved amount. The notice must include information about the charge for the surgery, the Medicare approved amount for the procedure, and what out-of-pocket expenses the patient should expect to pay. Surgeons should document patients’ receipt and acknowledgement of their expected financial responsibility. Surgeons who do not provide this notice to Medicare beneficiaries prior to furnishing an applicable elective surgery will be required to refund any money collected from the patient in excess of the Medicare approved amount.

How are PAR and non-PAR payments different?

Payments made to PAR and non-PAR providers differ in (1) the fee that is charged, (2) the amount paid by Medicare and the patient, and (3) where Medicare sends the payment. The table below shows how providers would be paid for a service with a $100 PFS allowed amount based on their Medicare payment arrangement.

Payment for a Service with $100 PFS Allowed Amount: PAR vs. Non-PAR

Payment arrangement

Total payment rate

Payment amount from Medicare

Payment amount from patient

PAR provider with assigned claim

100% Medicare PFS allowed amount = $100

$80 (80%) directly to provider

$20 (20%) copayment paid by patient or supplemental insurance

Non-PAR provider with Medicare assigned claim

95% Medicare PFS allowed amount = $95

$76 (80%) directly to patient for provider reimbursement

$19 (20%) copayment paid by patient or supplemental insurance

Non-PAR provider with unassigned claim

Limiting charge of 115% of 95% Medicare PFS allowed amount (effectively, 109.25% Medicare PFS allowed amount) = $109.25

$0

$76 (80%) paid by Medicare to patient + $19 (20%) copayment paid by patient or supplemental insurance + $14.25 balance bill paid by patient

What does it mean to opt out of Medicare participation?

Providers who do not wish to enroll in the Medicare program may opt out, meaning that neither a provider nor their patient can submit a bill to Medicare for reimbursement for services rendered. Providers who opt out may enter private contracting agreements with Medicare beneficiaries and charge patients without being subject to PFS. Such contracts, which must be signed by both the provider and patient, indicate that neither party will be reimbursed by Medicare for any Medicare-covered services or items. Providers are prohibited from opting out on a claim-by-claim or patient-by-patient basis.
In order to properly opt out of Medicare, providers must file an affidavit with CMS in which they agree to forgo Medicare reimbursement and to meet certain other criteria. While CMS does not offer a standard opt-out affidavit form, many Medicare Administrative Contractors (MACs) have forms available on their websites. Opt-out affidavits must:

  • Be in writing and signed by the filing provider
  • Include various statements indicating that the filing provider agrees to not submit claims to Medicare for any services furnished during the opt-out period, except for emergency or urgent care services furnished to beneficiaries with whom the provider has not previously entered into a private contract
  • Identify the filing provider sufficiently so that the appropriate Medicare contractor can ensure that no payment is made to the provider during the opt-out period
  • Be filed with all Medicare contractors who have jurisdiction over the claims the provider would have otherwise filed with Medicare
  • Be filed no later than 10 days after entering into the first private contract with a Medicare beneficiary

PAR providers who wish to opt out of Medicare may do so at beginning of each calendar quarter (January, April, July, or October). A valid opt-out affidavit postmarked 30 days before the first day of each new quarter must be submitted. Non-PAR providers may opt out at any time; however, the date on which the opt-out becomes effective must be after the date on which the provider signs the affidavit. Once providers have opted out of Medicare, they cannot submit claims to Medicare for any of their patients for a two-year period.

Are providers who opt out of Medicare still eligible for Medicare reimbursement for emergency or urgent care services furnished to a beneficiary?

Providers who have opted out of Medicare may be eligible for reimbursement for emergency or urgent care services furnished to a Medicare beneficiary, even if they have not previously entered into a private contract with the patient, if the provider:

  • Submits a claim in accordance with Medicare payment requirements and other instructions, including but not limited to complying with proper coding of emergency or urgent care services furnished by physicians who have opted out of Medicare
  • Collects no more than the Medicare charge

Are there penalties for violating a Medicare assignment agreement?

Providers who violate a Medicare assignment agreement by attempting to collect payment from beneficiaries for any amount other than copayment, non-covered charges or unmet deductibles may face one of the following penalties:

  • Fines of up to $2,000 per item or service claimed
  • Exclusion from Medicare participation
  • Exclusion from State health insurance participation

When can surgeons enroll in or make changes to their Medicare participation agreements?

MACs conduct an annual open participation enrollment period in order to offer providers an opportunity to make their calendar year Medicare participation decision. During open enrollment, which typically occurs from mid-November through December 31 each year, providers can choose to enroll in the Medicare program, maintain their participation status, or modify their participation status. Providers must make their 2018 Medicare participation determination by December 31, 2017. Participation agreements will cover the period from January 1, 2018 through December 31, 2018, and may not be changed once open enrollment has ended (with limited exceptions).

What steps should surgeons take to participate in the Medicare program?

  • Obtain a national provider identifier (NPI). Providers must be assigned an NPI before enrolling in the Medicare Program. Visit the National Plan and Provider Enumeration System website to apply for an NPI.
  • Complete the proper Medicare enrollment application. Once an NPI is obtained, providers can submit either a paper enrollment application (CMS-855I) or complete an electronic enrollment application through the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) online portal.
  • Await application processing. MACs screen and verify all provider information on the enrollment application. Once the applicable MAC approves an application, providers will receive an approval letter and will be designated as “approved” on PECOS.
  • Finalize enrollment. Providers must submit the Medicare Participating Physician or Supplier Agreement (CMS-460) to the appropriate MAC in order to finalize their enrollment. Providers have 90 days from when the CMS-460 form is submitted to decide to maintain their participation status or revoke their enrollment. Once a provider becomes a Medicare participant, they must remain a participant until the following annual enrollment period conducted by their MAC. 
  • Keep enrollment information up to date. Providers must revalidate their Medicare enrollment record information every three to five years using PECOS or the appropriate paper application (CMS-855I). Providers who are actively enrolled in Medicare may check the Medicare Revalidation Lookup Tool to find their revalidation due date.  In the event that a provider experiences a change of information (e.g., change of practice address or ownership) after their revalidation due date, they should update their record in PECOS within 30 days of the reportable event.

How can surgeons compare each participation option to determine which option is the best fit for their practice?

See the table below for a comparison of the three Medicare participation options.

Medicare Participation Options

 

PAR

Non-PAR

Opt-out

Contracting

Providers are contractually obligated to accept assignment on all Medicare claims.

Providers do not contract with Medicare but may accept Medicare claims assignment on a case-by-case basis.

Providers do not contract with Medicare but may privately contract with Medicare beneficiaries.

Participation determination deadlines

Providers may elect to participate in Medicare between mid-November and December 31, 2017.

Providers may elect to revoke their Medicare participation between mid-November and December 31, 2017.

PAR providers who wish to opt out of Medicare may do so at beginning of each calendar quarter. Non-PAR providers may opt out at any time.

Billing and payment

Providers bill Medicare directly and are reimbursed by Medicare directly.

Providers bill Medicare directly. Medicare issues payments to patients for the services rendered. Patients are responsible for sending Medicare payments to providers.

Providers bill patients directly. Patients pay providers out-of-pocket.

Reimbursement rates

Medicare reimbursement is 5% higher than the non-PAR amount.

Medicare reimbursement is 5% lower than the PAR amount, even for assigned claims.

Medicare does not offer reimbursement for providers who have opted out, with the exception of providers who furnish emergency or urgent care services to Medicare beneficiaries.

Limiting charges

PAR claims are not subject to the Medicare limiting charge.

Non-PAR unassigned claims cannot exceed the Medicare limiting charge.

Providers who have opted out cannot submit claims to Medicare and are not subject to the Medicare limiting charge.
Opted-out providers who furnish emergency or urgent care may submit claims to Medicare, but cannot charge patients more than the Medicare limiting charge.

Surgeons who have questions about participating in, or opting out, of the Medicare program may contact Lauren Foe, ACS Division of Advocacy and Health Policy, at lfoe@facs.org.