Understanding PAR and non-PAR Providers with Medicare

1
(No Transcript)
2
Understanding PAR and non-PAR Providers with
Medicare
PAR and non-PAR Providers with Medicare The
Center for Medicare Medicaid Services (CMS) is
a federal agency within the Department of Health
and Human Services which manages and oversees the
Medicare program for beneficiaries. Physicians
are required to comply with numerous laws and
regulations related to various aspects of their
practice within the Medicare program. Each year
physicians have the opportunity to review and/or
modify their contractual relationship within the
Medicare program. Participating providers are
referred to as PAR while non-participating
providers are referred to as Non-PAR. It is
important for providers to understand their
options within the program to ensure proper
reimbursement. The primary difference between
being a PAR and a non-PAR Provider lies in how
fees will be collected.
3
Understanding PAR and non-PAR Providers with
Medicare

• The three Medicare contractual options available
  for physicians are as follows
• Participating (PAR) providers can sign a
  participating agreement and accept Medicares
  allowable charges as payment in full for all
  their Medicare patients.
• Non-participating (non-PAR) providers may elect
  to be non-PAR physicians, which permits them to
  make assignment decisions on a case-by-case basis
  and allows the option to bill patients more than
  Medicare allows for unassigned claims.
• In private contracting as a private contracting
  physician, the provider agrees to bill his/her
  patients directly and forego any payments from
  Medicare. 
• Physicians have the ability to change their
  status from PAR to non-PAR or vice versa
  annually. Once made, the decision is generally
  binding until the next annual contracting cycle.
  Medicare status can change in between contracting
  spans where the physicians practice situation
  has changed significantly, such as relocation to
  a different geographic area or a different group
  practice.
• To become a private contractor, physicians must
  give Medicare 30 days notice before the first
  day of the quarter when the contract will take
  effect. Providers considering a change in their
  Medicare status must first

4
Understanding PAR and non-PAR Providers with
Medicare
determine that they are not bound by any
contractual arrangements with hospitals, health
plans, or other entities that require them to be
PAR physicians. In addition, it is essential to
understand and verify any state laws that have
been enacted prohibiting physicians from balance
billing their patients. Participating (PAR)
Providers with Medicare Participating in the
Medicare program means the healthcare
professional agrees to accept assignments for all
services provided to Medicare beneficiaries. By
accepting an assignment, it states that the
provider agrees to accept the amount approved by
Medicare as the total payment for covered
services. The deductible and/or coinsurance are
applied to covered services and the beneficiary
is responsible for these amounts. When a
provider enrolls as a new provider to become a
participant, Medicare allows 90 days from the
date of your Provider Identification Number (PIN)
notification to change your participation
status. If a PAR agreement is received within 90
days of enrollment, the PAR effective date will
be the postmark date on the envelope.
5
Understanding PAR and non-PAR Providers with
Medicare

• If the decision is made to enroll as a Medicare
  participating provider after the 90-day grace
  period, the individual provider must wait and
  complete a form during open enrollment and is
  obligated to remain a participant until the
  following annual enrollment period.
• Why you should be PAR with Medicare?
• Your Medicare fee schedule amount is 5 higher
  than that of a non-participating provider.
• Collections from patients are much easier because
  Medicare reimburses 80 of the allowed charges to
  the provider and the practice will have to
  collect the remaining 20 from the beneficiary.
• Medicare will automatically forward Medigap
  claims to the proper insurer for payment when
  they receive the completed claim form. This
  one-stop billing eliminates the need to submit
  a separate bill to the supplementary insurer or
  beneficiary after receiving Medicares payment.
• Participation also improves the relationship with
  the beneficiary as it helps reduce any
  out-of-pocket expenses that will be the
  responsibility of the beneficiary.
• Non-Participating (non-PAR) Provider with
  Medicare

6
Understanding PAR and non-PAR Providers with
Medicare
If a provider makes the decision to not be a
participating provider in the Medicare program,
they will have to choose either to accept or not
accept assignments on Medicare claims on a
claim-by-claim basis. If you choose not to accept
the assignment, you may not charge the
beneficiary more than what Medicare has capped as
the limit for unassigned claims for services
covered by Medicare. The limiting charge applies
to non-participating providers in the Medicare
Part B program when they do not accept
assignments and is usually 115 of the physician
fee schedule amount. Keep in mind, that Medicare
beneficiaries are not responsible for billed
amounts in excess of the limiting charge for a
covered service. If you choose not to
participate in the Medicare program and do not
accept assignments on claims, the maximum amount
to charge is 115 of the approved fee schedule
amount for non-participating providers. This
amounts to only 9.25 more than the fee schedule
amount for participating providers. PAR Vs
Non-PAR Providers
7
Understanding PAR and non-PAR Providers with
Medicare
Participating providers must accept assignments
while non-participating providers may collect
up-front from the patient. Essentially, if you
are a participating provider, your patient will
only pay any deductible and/or co-insurance at
the time of service and then Medicare reimburses
the allowed fee after the claim is
billed. Non-participating providers may collect
their allowed fees in full from the patient and
the beneficiary will be partially reimbursed by
Medicare. For non-covered services, regardless of
status, payment may be collected up-front from
the patient. Changing the Status If you are
currently a non-participating provider and wish
to participate, you will have to contact your
carrier for a participation agreement. If you are
currently a participating provider and wish to
become non-participating, you will need to submit
a letter (on office letterhead) to your local
carrier or administrative contractor stating your
intent. This letter must include the original
signature of the authorized representative or
individual provider. If you are not sure how to
handle the contracting process, we can assist you.
8
Understanding PAR and non-PAR Providers with
Medicare
About Medical Billers and Coders Medical Billers
and Coders (MBC) is a leading outsourcing medical
billing company providing complete revenue cycle
services including Medicare credentialing and
contracting services. To learn more about our
Medicare billing and coding services, email us
at info_at_medicalbillersandcoders.com or call us
at 888-357-3226 FAQs 1. What is par and
non-par? PAR stands for Participating, while
non-PAR stands for Non-participating. 2. What
does it mean if a provider is par? If a provider
is PAR, it means they accept Medicares approved
charges as full payment for services provided to
Medicare patients. 3. What is a non-par Medicare
provider?
9
Understanding PAR and non-PAR Providers with
Medicare
A non-PAR Medicare provider is one who hasnt
agreed to accept Medicares approved charges as
full payment and may charge patients more than
what Medicare allows. 4. When a Medicare patient
seeks care from a non-PAR provider? When a
Medicare patient seeks care from a non-PAR
provider, they may have to pay more out-of-pocket
because the provider doesnt accept Medicares
approved charges as full payment. 5. What is the
difference between par and non-par Medicare
providers? The main difference is that PAR
providers accept Medicares approved charges as
full payment, while non-PAR providers may charge
patients more and dont have to accept
assignments on Medicare claims.