Medicare: Participating and Non-Participating Providers

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Every audiologist must decide if they should participate or not with Medicare, as well as, other third party payors. Most seniors and people in general do look for providers who accept their insurance, so choosing not to participate can have devastating negative affects on a healthcare business. That said, randomly participating with all third party payors without understanding the terms of that participation, including reimbursement levels and potential risks, can also be devastating to an audiology business.

With Medicare, physicians and "qualified practitioners" have three choices;participate as a "participating provider", participate as a "non-participating provider", or "opt-out";however, audiologists are not physicians nor are they considered "qualified practitioners" by CMS and therefore cannot opt-out or offer a private contract to Medicare beneficiaries. An audiologist's chosen status (par or non-par) with Medicare will dictate who you bill, how much you collect for a given procedure and the responsible party. If a Medicare beneficiary requests that an audiologist bill Medicare for the services performed, that audiologist is legally required to do so per the Mandatory Claims Statute.

Although Medicare is a federally funded program, it is also administered by state or regional intermediaries who have been know to interpret Medicare (federal) policy differently. It is always wise to identify and document in writing any information that is provided to you by your intermediary including the name and contact information of the person providing the information. The sources of information for this article were Fred Graubau from the Center for Medicare & Medicaid Services (CMS) via Deb Abel, Au.D. from the American Academy of Audiology (AAA).

As a general rule:

"Participating Providers" accept assignment from Medicare. The provider bills Medicare at their usual and customary fee;however, Medicare pays the provider 80% of the "allowed amount" for each CPT code. Patients are responsible for 20% of the allowed amount and this 20% should not be waived. The provider cannot bill patients for amounts in excess of the allowed amount and must write off the difference between the allowed amount and usual and customary fees.

"Non-participating Providers" do in fact participate with Medicare. Non-par providers generally do not accept assignment on a regular basis;however, can choose to accept assignment on a case-by-case basis and be reimbursed at the non-par level. Non-par providers must also bill Medicare, but Medicare reimburses the patient versus the provider. The amount patients receive from Medicare will be 5% less than the par-allowed amount and the patient pays the provider for services rendered.

A non-par provider can legitimately increase reimbursement by charging the "limiting fees", which represent the maximum allowable reimbursement. Limiting fees, as well as, par and non-par allowed fees can vary by region, state, and even city and can be found at www.cms.gov.

"Opting-Out" Although physicians and qualified practitioners can "opt-out" of participation with Medicare, this option does not currently exist for audiologists according to Fred Graubau at CMS, even though audiologists are legally authorized to practice with a state license and otherwise meet Medicare requirements including being licensed to perform Medicare covered services, must bill using a unique NPI and can receive reimbursement directly from Medicare.

It is very important to understand the impact (positive and negative) third party payor participation can have on one's practice before committing to any level of provider status.

Kathy Foltner, AuD, is CEO of AuDNet, Inc. She also teaches courses in Practice Management and Basic Business at Rush University Medical Center and PCO. Dr. Foltner can be reached at kfoltner@aud-net.com or 312-593-1787.

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