Medicare enrollment and participation

Physicians, nonphysician practitioners, and other Medicare Part B suppliers are required to enroll in the Medicare program to receive compensation for covered services provided to Medicare beneficiaries. Providers must make their 2020 Medicare determinations by December 31. As the deadline approaches and providers consider their options with respect to Medicare participation, this column provides guidance to assist Fellows in navigating their contractual relationships with the Centers for Medicare & Medicaid Services (CMS).

What are the participation options?

Three participation options are available to surgeons:

• Sign a participation (PAR) agreement: PAR surgeons choose to participate in the Medicare program and agree to provide all covered services for all Medicare beneficiaries on an assigned claims basis.
• Elect non-participation (non-PAR): Non-PAR surgeons may choose on a case-by-case basis whether to accept Medicare assignment of claims. Surgeons 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): Surgeons who opt out of Medicare participation must bill their patients directly and forgo any Medicare reimbursement.

How are PAR surgeons paid?

PAR surgeons are contractually obligated to accept Medicare assignment for all claims submitted for covered services furnished to Medicare beneficiaries. By agreeing to always accept assignment, surgeons also agree to always accept Medicare physician fee schedule (PFS)-allowed amounts as payment in full and not to collect more than the Medicare deductible and coinsurance or copayment from any beneficiary.

How does CMS determine payment for non-PAR surgeons?

When non-PAR surgeons accept assigned claims, they receive a total Medicare payment that is 5 percent lower than reimbursement to PAR surgeons. Non-PAR surgeons are not reimbursed directly by Medicare for the assigned claims they submit; instead, Medicare pays patients for 80 percent of a service’s PFS amount. Patients are then responsible for passing along to the surgeon the Medicare payment plus the 20 percent copayment, which may be covered by supplementary insurance.

For unassigned claims, non-PAR surgeons may bill up to 115 percent of the PFS-allowed amount, known as the “limiting charge.” The limiting charge is the maximum amount a non-PAR surgeon may legally charge a patient when filing an unassigned claim.

What is the difference between PAR and non-PAR reimbursement?

Payments made to PAR and non-PAR surgeons differ in three ways: the fee that is charged, the amount Medicare and the patient each pay, and where Medicare sends the payment. Table 1 shows how surgeons would be paid for a service with a $100 PFS-allowed amount based on their Medicare payment arrangement.

Table 1. PAR and non-PAR reimbursement

What if I want to opt out of Medicare participation?

Surgeons who opt out of Medicare cannot bill CMS or Medicare beneficiaries for services rendered, but instead may enter private contracting agreements with Medicare beneficiaries and charge patients without being subject to the MPFS. Such contracts, which must be signed by both the surgeon and patient, indicate that neither party will receive Medicare reimbursement for any covered services. Surgeons are prohibited from opting out on a claim-by-claim or patient-by-patient basis.

To opt out, surgeons are required to file an affidavit with CMS in which they agree to forgo Medicare reimbursement. CMS does not offer a standard opt-out affidavit form, but many Medicare Administrative Contractors (MACs) have forms available on their websites.¹

PAR surgeons may opt out of Medicare at the beginning of each quarter of the calendar year (January, April, July, or October). Non-PAR surgeons may opt out at any time.

How do I enroll?

Surgeons may make their Medicare participation decision for the upcoming calendar year during the designated annual open enrollment period, typically mid-November through December 31. Participation agreements for 2020 will cover the period from January 1 through December 31 and may not be changed once open enrollment has ended.

Surgeons should take the following steps to successfully enroll and participate in the Medicare program.

Obtain an NPI

You must be assigned a unique 10-digit national provider identifier (NPI) before enrolling in the Medicare program. To receive an NPI, submit an online, paper, or Electronic File Interchange application.² If you have already applied, you can access the identifier via the National Plan and Provider Enumeration System NPI Registry.³

Complete the proper Medicare enrollment application

Once an NPI is assigned, you may enroll in the Medicare program, revalidate your enrollment, or change your enrollment information. Review CMS’ Medicare enrollment checklist to ensure you have all the required information before initiating the application process.⁴

You may submit either a paper enrollment application⁵ or complete an electronic enrollment application through the Medicare Provider Enrollment, Chain, and Ownership (PECOS) online portal.⁶

To avoid delays in application processing, verify the following before submission:

• All required forms are appropriately signed and dated
• All data elements are completed accurately
• Supporting documents (tax forms, proof of licensure, and so on) are attached

If you are applying for Medicare enrollment, you also must pay an application fee electronically via PECOS. Applications will be rejected if the fee is not paid within 30 days of the application submission.

Await application processing and respond to requests for more information

MACs process and screen all provider information on the enrollment application once it is submitted and may employ additional review methods (for example, licensure verification, documentation requests, site visits) as needed. Respond to any requests from your MAC as soon as possible, but within 30 days of the request. Failure to do so may delay enrollment or result in the rejection of the submitted application.

Once a MAC has determined a surgeon is eligible for Medicare billing privileges, it will send the surgeon an approval letter and will designate the surgeon as “approved” in PECOS.

Finalize enrollment

After receiving approval, a surgeon must submit the Medicare Participating Physician or Supplier Agreement (CMS-460) to the appropriate MAC to finalize enrollment.⁷ You have 90 days from when the CMS-460 is submitted to decide to accept your participation status or revoke your enrollment. If you choose to become a Medicare PAR, you continue to participate until your MAC’s next annual enrollment period begins.

Keep your information up-to-date

You should regularly verify the accuracy of your enrollment information on file with CMS and must formally revalidate your Medicare enrollment record every five years. If you are actively enrolled in the program, use the Medicare Revalidation Lookup Tool to find your revalidation due date.⁸ If you submit your application after the due date, your MAC may place a hold on your Medicare payments or revoke your billing privileges. In the event that your information changes following revalidation (for example, your practice moves to a different location), you should update your information in PECOS within 30 days of the event.

Where can I find more information about Medicare participation?

For more information about the Medicare provider enrollment process, review the Medicare Learning Network Part B Enrollment Booklet or visit the ACS website. Contact Lauren Foe, Senior Regulatory Associate, ACS Division of Advocacy and Health Policy, at lfoe@facs.org with questions.

References

1. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare fee-for-service provider enrollment contact list. Available at: www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/contact_list.pdf. Accessed November 4, 2019.
2. Department of Health and Human Services. Centers for Medicare & Medicaid Services. National Provider Identifier (NPI) application/update form. Available at: www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS10114.pdf. Accessed November 4, 2019.
3. National Plan & Provider Enumeration System. Electronic file management main page. Available at: https://nppes.cms.hhs.gov/webhelp/nppeshelp/EFI%20HELP%20PAGE.html. Accessed November 4, 2019.
4. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Checklist for individual physician and non-physician practitioners using PECOS. Available at: https://pecos.cms.hhs.gov/pecos/help-main/prctnrchecklist.jsp. Accessed November 4, 2019.
5. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare enrollment application. Available at: www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855i.pdf. Accessed November 4, 2019.
6. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Welcome to the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). Available at: https://pecos.cms.hhs.gov/pecos/login.do#headingLv1. Accessed November 4, 2019.
7. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare participating physician or supplier agreement. Available at: www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS460.pdf. Accessed November 4, 2019.
8. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Enrollment for Physicians, NPPs, and Other Part B Suppliers. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_PhysOther_FactSheet_ICN903768.pdf. Accessed November 4, 2019.