In light of the recent focus on the 2015 reduction in fee schedule many are wondering how it pertains to the “non-par” providers. The answer was not readily available on the CMS website so, I went digging for answers. But first we need to understand the difference between “par” and “non-par” Medicare providers. Here is what I found:
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 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.
When a provider chooses to be “non-par” there are special billing guidelines to follow.
The ACA outlines these guidelines as follows:
“Billing as a Non-Participating Provider
For non-participating providers, the process is different. If you are non-par, not accepting assignment, and the patient’s deductible has not been met, you are subject to charging a maximum of the limiting charge (determined by your fee schedule). Your patient pays you the full amount of up to the limiting charge, you bill Medicare for the fee (up to the limiting charge), and Medicare applies the non-par allowable fee to the patient’s deductible.
If you are non-participating, not accepting assignment, and the deductible has been met, your patient would still pay you up to the limiting charge and you would still bill Medicare for that amount. Medicare would then reimburse the patient 80% of the non-par allowable fee.
If you are a non-participating provider that accepts assignment, you must accept the non-par allowable as payment in full. If the patient’s deductible has not been met, the patient pays the full non-par allowable. If the patient’s deductible has been met, the patient would be responsible for 20 percent of the non-par allowable fee and Medicare would reimburse you for the remaining 80 percent. Again, as with par, any difference between allowed and billed fees must be written off.”
In a nutshell, if you are “non-par” and you do not accept assignment you can only submit fees up to the limiting charge. If you are a “non-par and you accept assignment you can only submit fees up to the non-par allowable fee. The key here is that you cannot bill your usual and customary fees in either situation.
Chiropractors can not “opt out” of Medicare. (See article below#4)
Here is the email response I received from CMS regarding “non-par” guidelines for meaningful use:
“Dear Sir or Madam,
Thank you for your recent inquiry. Below is the information you requested about payment adjustments and eligibility for non-participating Medicare part B providers.
The purpose of the EHR Incentive Program is to promote the use of electronic mechanisms for maintaining and providing information, participation in the incentive program is voluntary.
“An EP that is not a Medicare participating physician or supplier, but still submits claims to Medicare for Part B physician fee schedule services on behalf of Medicare patients to whom they furnish services would be eligible for Medicare EHR incentive payments. When the EP successfully registers and demonstrates meaningful use of certified EHR technology, the calculation of the EP’s incentive payment will reflect claims for all services reimbursed under the Part B physician fee schedule regardless of whether the EP accepted assignment on those claims or not.
Payment adjustments for any Medicare provider who does not demonstrate meaningful will begin in 2015.”
So, what does that mean? Simply that chiropractors do not have the option to “opt out” of caring for Medicare patients. They can choose to participate or not and/or accept assignment or not. Regardless of your participation status chiropractors treating Medicare eligible patients are required to meet the documentation standards of CMS. They are also eligible for the incentive AND subject to the penalties.
The moral of the story…Achieve Meaningful Use! This is our roadmap to higher reimbursement as we show lawmakers that we are on board with the transition to an outcomes-based fee schedule. To learn more visit the North Carolina Chiropractic Associations website at www.ncchiro.org and sign up for the next Achieving Meaningful Use seminar. (Accredited for 8 CEU’s in North Carolina) Please leave your questions or comments below.