| Open Enrollment - 3 Options for Providers |
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 Given the uncertainty of adequate payment rates, physicians often inquire about their participation options with respect to Medicare.
There are three choices for physicians:
- Participating: Physicians may elect to participate and accept Medicare's allowed charges (i.e. Medicare's physician fee schedule) as payment in full for covered services for all of their Medicare patients;
- Non-Participating: A non-participating physician must abide by Medicare limiting charges but may choose from two options for their reimbursement on a claim-by-claim basis. The two billing options are:
- Bill Medicare directly. Providers can accept assignment of benefits from the patient and get reimbursed directly from Medicare at the non-participating rate, which is equal to 95% of the rate from participating physicians.
- Bill directly and collect from the Medicare patient, but only at a rate of 9.25% more than the amounts allowed in the participating physician fee schedule (i.e., 109.25% of the Medicare fee schedule).
- Opt-out: Physicians may opt-out of the Medicare program entirely (for 2-year periods) and privately contract with their Medicare patients for medical services, whether or not they are covered by Medicare. Physicians are bound only by their private contracts with their patients. Medicare's limiting charges do not apply to these contracts, although these contracts must contain certain terms.
Typically, providers may only change their participating status to non-participating during the open enrollment, which is typically from mid-November through December 31.
Physicians who wish to opt out of the Medicare program entirely must do so before the first day of the next calendar quarter (i.e., January 1st, April 1st, July 1st, and October 1st). |
