I received my National Provider Identifier (NPI) number and want
to start seeing Medicare patients, but I have to decide between being a
participating provider or nonparticipating provider within the Medicare
program. What do you recommend?
You will need to decide
whats best for your particular situation after reviewing the
differences between being a participating and nonparticipating provider
keeping in mind that participating and nonparticipating providers
must follow the same rules and regulations as it pertains to proper and
compliant documentation.
For example: Medicare participating and nonparticipating providers need to establish the existence of spinal subluxation through the P.A.R.T. exam or x-rays, understand the AT, GA, GP, GY, and GZ modifiers create treatment plans with specific treatment goals, choose compliant CPT/ICD-9 codes, know when and how to incorporate the ABN form, and know how to document the initial and subsequent visits properly.
TO PARTICIPATE
A Medicare participating provider is one who voluntarily and in advance enters into an agreement in writing to provide all covered services for all Medicare Part B beneficiaries on an assigned basis. A participating provider:
Agrees to accept Medicare-approved amount as payment in full; and
May not collect more than the applicable deductible and coinsurance for covered services from the patient. Payment for noncovered services may also be collected.
Additionally, Medicare providers understand that:
Charges are not subject to the limiting charge;
Medicare payment is paid directly to the provider;
Mandatory claims submission applies;
Their name appears in the directory of participating providers (MEDPARD);
Reimbursement is 5 percent higher than the nonparticipating amount; and
Medigap information is transferred.
NONPARTICIPATING PROVIDERS
Medicare nonparticipating providers are those who have not entered into an agreement to accept assignment on all Medicare claims. They:
Can elect to accept assignment or not accept assignment on a claim-by-claim basis; and
Cannot bill the patient more than the limiting charge on non-assigned claims.
Additionally, if you are a nonparticipating provider, you understand that:
The beneficiary receives payment on non-assigned claims;
Mandatory claims submission applies;