November 09, 2022
It’s that time of year again—time for physicians to decide if they want to make changes to their Medicare participation status. Physicians have until December 31, 2022, to make changes for the 2023 participation year. The effective date for any changes made will be January 1, 2023.
In making the decision for the 2023 participation year, physicians should be aware that the Centers for Medicare and Medicaid Services (CMS) recently released the final rule and policies for next year. Unless Congress acts by the end of the year, physicians are again facing substantial Medicare payment cuts in 2023 due to a confluence of statutory and budget neutrality payment cuts. The California Medical Association (CMA) is urging Congress to stop the 4.5% cut for all physician services in the 2023 Medicare Physician Fee Schedule.
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 2023 must submit a signed Medicare Participating Physician or Supplier Agreement (CMS-460) to Noridian, California’s Medicare contractor, postmarked by December 31, 2022. 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.
There is also information on physicians' Medicare participation options in the CMA 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.
Click here for more information on open enrollment from the Noridian website.
Contact: Cheryl Bradley, (916) 551-2862 or firstname.lastname@example.org.