November 09, 2016
Area(s) of Interest: MACRA Payor Contracting Practice Management Payor Issues and Reimbursement
Once again, it’s time for physicians to decide if they want to make changes to their Medicare participation status. Physicians have until December 31, 2016, to make changes for 2017.
Although Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) penalties will not kick in until 2019, there are two more years of penalties that will be applied based on 2015 performance—tied to the meaningful use, Physician Quality Reporting System and Value-Based Modifier reporting programs. This will also decrease the limiting charge amounts that nonparticipating physicians can bill to patients for unassigned claims.
As always, physicians have three choices regarding Medicare: Be a participating provider; be a non-participating provider; or opt out of Medicare entirely. Details on each of the three participations options are as follows:
- A participating physician must accept Medicare-allowed charges as payment in full for all Medicare patients.
- A non-participating provider can make assignment decisions on a case-by-case basis and bill patients for more than the Medicare allowance for unassigned claims. Non-participating physician fees are 95 percent of participating physician fees. If you choose not to accept assignment, you can charge the patient 9.25 percent more than the amounts allowed in the participating physician fee schedule (which equates to 15 percent of the non-participating fees).
- Physicians who opt out of Medicare are bound only by their private contracts with their patients. Medicare's limiting charges do not apply to these contracts, but Medicare does specify that these contracts contain certain terms. When a physician enters into a private contract with a Medicare beneficiary, both the physician and patient agree not to bill Medicare for services provided under the contract.
Physicians who want to change their participation status for 2017 must send a letter to Noridian, California’s Medicare contractor, postmarked by December 31, 2016.
The California Medical Association (CMA) also has information on physicians' Medicare participation options in CMA On-Call document #7209, "Medicare Participation (and Nonparticipation) Options." On-Call documents are free to members in CMA's health law library. Nonmembers can purchase On-Call documents for $2 per page.
Physicians can also visit CMA’s MACRA resource center to better understand the payment reforms and access resources to help with the transition. The center is a one-stop-shop with tools, checklists and information from CMA, the Centers for Medicare and Medicaid Services, the American Medical Association and national specialty society clinical data registries.
Contact: Cheryl Bradley, (213) 226-0338 or firstname.lastname@example.org.