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Can a Non-participating Provider bill Medicare?

Being non-par does not mean you don’t have to bill Medicare. All Medicare part B covered services must be billed to Medicare by the provider or the provider could face penalties. This is known as the “Mandatory Claim Submission Rule” (an exception to this is when the beneficiary has signed a valid Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, with Option #2 selected.

A non-par provider is actually someone who has enrolled to be a Medicare provider but chooses to receive payment in a different method and amount than Medicare providers classified as participating. Non-par providers may receive reimbursement for rendered services directly from their Medicare patients; however, they still must submit a bill to Medicare so the beneficiary may be reimbursed for the portion of the charges for which Medicare is responsible.

It is important to note that non-par providers may also choose to accept assignment; therefore, the amount paid by the beneficiary must be reported in Item 29 of the CMS 1500 claim form or its electronic equivalent. This ensures that the beneficiary is reimbursed (if applicable) prior to Medicare sending payment to the provider.

Whether or not non-par providers choose to accept assignment on all claims or on a claim-by-claim basis, Medicare reimbursement is five percent less than for a participating provider, as reflected in the annual Medicare Physician Fee Schedule. 

You can find a copy of the Medicare Participating Provider Agreement at http://www.cms.gov/cmsforms/downloads/cms460.pdf on the CMS website. The form contains important information regarding the participation process and the annual opportunity  you have to make or change your participation decision. Additional information is available in the Medicare Benefit Policy Manual (Chapter 15; Covered Medical and Other Health Services) at http://www.cms.gov/manuals/Downloads/bp102c15.pdf and the Medicare Claims Processing Manual (Chapter 12; Physician/Nonphysician Practitioners) at http://www.cms.gov/manuals/downloads/clm104c12.pdf on the CMS website.

It is not true that 'If you are a non-par provider, you will never be audited nor have claims reviewed, etc.'  Any Medicare claim submitted can be audited/reviewed; the participation status of the physician does not affect the possibility of this occurring. CMS audits/reviews are intended to protect Medicare trust funds and also to identify billing errors so providers and their billing staff can be alerted of errors and educated on how to avoid future errors. Correct coverage, reimbursement, and billing requirements are readily available to assist you in understanding Medicare requirements.

This information is in Medicare manuals that are at http://www.cms.gov/Manuals/ on the CMS website. In addition, an excellent way to stay informed about changes to Medicare billing and coverage requirements is to monitor MLN Matters® Articles, which are available at http://www.cms.gov/MLNMattersArticles/ on the same site.

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