Medicare participation: Know your options

Physicians, nonphysician practitioners, and other Medicare Part B suppliers must enroll in the Medicare program to be paid for covered services furnished to Medicare beneficiaries. Providers must make their 2018 Medicare participation determination by December 31. As this deadline approaches, many providers are considering their options with respect to Medicare participation and the implications of their decision. The American College of Surgeons provides guidance to assist Fellows in navigating their contractual relationships with Medicare.

Medicare participation options for surgeons

Three options are available to surgeons who participate in Medicare Part B:

  • Sign a participation (PAR) agreement. Providers who choose to participate in the Medicare program agree to always accept Medicare claims assignment for all covered services furnished to Medicare beneficiaries.
  • Elect nonparticipation (non-PAR). Providers who select the non-PAR option may choose to either accept or not accept Medicare assignment of claims on a case-by-case basis. Providers who do not accept Medicare assignment may bill patients for more than the Medicare-allowed amount for a particular service.
  • Become a private contracting physician (opt out). Providers who opt out of Medicare participation must bill their patients directly and forego any Medicare reimbursement.

Participating providers are contractually obligated to accept the Medicare-approved amount as payment in full for all covered services rendered to Medicare patients. Participating providers may collect only the Medicare deductible and copayment from any beneficiary.

To finalize enrollment as a Medicare participant, providers must submit the Medicare Participating Physician or Supplier Agreement (Form CMS-460) to the appropriate Medicare Administrative Contractor (MAC). Providers have 90 days from when the CMS-460 form is submitted to decide whether to maintain their participation status or revoke their enrollment. Once a provider becomes a Medicare participant, he or she must remain a participant until the following annual enrollment period.

MACs conduct an annual open participation enrollment period in order to offer providers an opportunity to make their calendar year Medicare participation decision. During open enrollment, which typically occurs from mid-November through December 31 each year, providers can choose to enroll in the Medicare program, maintain their participation status, or terminate their participation. Participation agreements will be in effect from January 1 to December 31, 2018, and cannot be changed once open enrollment has ended.

Steps to participation

The steps for achieving Medicare participation are as follows:

  1. Obtain a national provider identifier (NPI). Providers must be assigned an NPI before enrolling in the Medicare program. Visit the National Plan and Provider Enumeration System website to apply for an NPI.
  2. Complete the proper Medicare enrollment application. Once an NPI is obtained, providers can submit either a paper enrollment application (Application CMS-855I) or complete an electronic enrollment application through the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) online portal.
  3. Await application processing. MACs screen and verify all provider information on the enrollment application. Once the applicable MAC approves an application, providers will receive an approval letter and will be designated as “approved” on PECOS.
  4. Keep enrollment information up to date. Providers must revalidate their Medicare enrollment record information every three to five years using PECOS or the appropriate paper application (Application CMS-855I). Providers who are actively enrolled in Medicare may check the Medicare Revalidation Lookup Tool to find their revalidation due date. In the event that a provider experiences a change of information (such as change of practice address or ownership) after their revalidation due date, they should update their record in PECOS within 30 days of the reportable event.

For more information about Medicare participation; ways to apply for, revalidate, or make changes to Medicare enrollment; and more, visit the ACS website or contact the ACS Division of Advocacy and Health Policy at regulatory@facs.org.

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