Physicians have until February 15, 2013, to change their Medicare
participation or non-participation status for 2013.
Due to Massachusetts state law, the options
available to Massachusetts physicians are significantly different than
for physicians in other states. Please read the material below
carefully.
The MMS is not advising or recommending any of the
options described in this document. The purpose of the document is to
ensure that physician making decisions about their Medicare
participation have the information about their options available to
them.
Physicians who are currently participating (PAR) and
who want to remain PAR for 2013 do not need to do anything to maintain
their current status. Likewise, physicians who are currently
nonparticipating (non-PAR) and who want to remain non-PAR for 2013 do
not need to do anything to maintain their current status. To switch from
being PAR to non-PAR for the coming year, however, or from non-PAR to
PAR, physicians will need to notify their Medicare carrier in writing
before February 15, 2013.
Once made, the decision about participation will be
binding throughout calendar year 2013 except where the physician’s
practice situation has changed significantly, such as relocation to a
different geographic area or a different group practice.
Those considering a change in status should
first determine that they are not bound by any contractual arrangements
with hospitals, health plans or other entities that require them to be
PAR physicians. In addition, Massachusetts law prohibits physicians from
balance-billing their patients.
Physicians practicing in Massachusetts have two
options: 1) participating physician, 2) non-participating
physician.
Participating physician
A physician must sign a participation agreement to become a
participating physician for Medicare. A participating physician agrees
to accept payment from Medicare based on a fee schedule that lists all
covered services, as well as the approved charge that Medicare will pay
for a particular service. This Medicare physician fee schedule is
normally updated and published annually in the Federal Register in early
November. A participating physician agrees that payment for Medicare
services based on the fee schedule represents the approved and full
charge. This means a physician cannot collect or balance bill an amount
in excess of the approved charge listed on the fee schedule for services
furnished to Medicare patients.
A participating physician also agrees to accept assignment on all
Medicare claims. This means that Medicare will pay 80% of the approved
fee schedule amount directly to the physician. The physician is
responsible for collecting the remaining 20% of the Medicare approved
charge from the patient.
The advantages of being a participating physician are threefold: (1)
physicians are reimbursed at 100% of the Medicare fee schedule amount
for covered services furnished to patients, (2) physicians also receive
80% of payment due directly from Medicare, which makes the claim process
easier and more certain, and (3) participating physicians are listed in
a "Medicare Participating Physician/Supplier Directory". This
directory is made available to individuals who contact Medicare
requesting the name of participating doctors as well as various senior
citizen groups.
Non-participating physician
A physician who does not participate in Medicare still faces limits
with respect to the amount he or she can collect from Medicare for
covered services furnished to patients. Medicare pays non-participating
Massachusetts physicians who accept assignment up to 95% of the Medicare
fee schedule. Non-participating physicians can charge their patients for
only the remaining 5% of the Medicare fee schedule.
If a non-participating physician does not accept assignment, Medicare
pays the patient for the claimed benefit, not
the physician. Thus it is up to the physician to collect the
entire payment for covered services directly from the patient. Under
current Massachusetts law the maximum allowable charge for a service is
equal to the Medicare fee schedule.
Non-participating physicians must also collect the entire
reimbursement from the patient, thus assuming a higher level of risk and
effort to collect fees. Furthermore, a non-participating physician's
patient volume may be lower because most patients prefer to see
participating physicians. It is easier and less costly for
patients to see participating physicians.
Sample Medicare Private Contract "Opt Out"
Affadavit. (.pdf, 2 pages)
