December 17, 2020
Area(s) of Interest: Public Payors
Once again, it’s time for physicians to decide if they want to make changes to their Medicare participation status. Due to the later release of the Medicare Physician Fee Schedule Final Rule, physicians have until January 31, 2021, to make changes for the 2021 participation year. The effective date for any changes made will be retroactive to January 1, 2021.
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 participating provider receives 5% more reimbursement than a non-participating provider.
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% of participating physician fees. If you choose not to accept assignment, you can charge the patient 9.25% more than the amounts allowed in the participating physician fee schedule (which equates to 15% 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. As a result of the Medicare Access and CHIP Reauthorization Action of 2015 (MACRA), validated opt-out affidavits signed on or after June 16, 2015, will automatically renew two years after the effective date.
Physicians who want to change their participation status for 2021 must submit a signed Medicare Participating Physician or Supplier Agreement (CMS-460) to Noridian, California’s Medicare contractor, postmarked by January 31, 2021. The participation agreement will automatically renew each year. However, if there is a name or EIN (tax identification number) change, you will need to complete a new participation agreement.
The California Medical Association (CMA) also has information on physicians' Medicare participation options in CMA’s health law library: document #7209, "Medicare Participation (and Nonparticipation) Options." Health law library documents are free to members at cmadocs.org/health-law-library. Nonmembers can purchase documents for $2 per page.
Physicians can also visit CMA’s MACRA resource center at cmadocs.org/macra to better understand the payment reforms of the Medicare Access CHIP Reauthorization Act of 2015 and how they impact physician practices. The resource 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.
Click here for more information on open enrollment from the Noridian website.
Contact: Cheryl Bradley, (213) 226-0338 or firstname.lastname@example.org.