The rules, pros and cons of being a Non-Participating Medicare Provider and how to decide what’s best for your practiceI’ve been getting a few similar questions about the pros and cons of being a Non-Participating Provider with Medicare, and would like to address them here. You can see this post on Medicare for details on what that means if you are not familiar, but just to quickly review…

There are three possibilities for a Physical Therapist’s relationship-status with Medicare:

1)   No relationship at all (not the same as a “Non-Participating Provider” and also not the same as “opting out”)

2)   Participating Provider

3)   Non-Participating Provider

A little more detail on the Non-Par Status: You can accept self-payment from the beneficiary at the time of service, but you still must send in the claim to Medicare. Medicare will then send any reimbursement directly to the patient. As a Non-Participating Medicare Provider, you can bill the patient up to 115% of the Medicare Fee Schedule.

So what kinds of questions does this status bring up? …

If you are a Non-Participating Provider, do you still have to deal with all the same paperwork, possible audits, and other hassles of Medicare? If so, what is the point of being a Non-Par provider?

I’ve never been a Non-Par Provider, but I know that you still have to bill Medicare directly so I would guess that your paperwork requirements would be very similar to Participating Providers. I’m sure the possibility of being audited is still there as well, but I’ don’t know if there are any differences in the chances of being audited. So what is the point? …

As a Non-Par Provider, unlike practitioners who have no relationship with Medicare, you can still provide “covered” skilled PT services for Medicare beneficiaries. This is hugely important for some practices in certain areas with certain demographics. Non-Par Providers can also take payment in full at the time of service directly from the beneficiary, so they are not waiting for a 3rd Party Payor to reimburse them. Furthermore, the billing can be up to 115% of the Medicare Fee Schedule, so you can get a little more money for your time as a Non-Par Provider.

Is the hassle of dealing with Medicare paperwork and regulations really worth the extra 15% you can bill as a Non-Participating Provider?

Dealing with Medicare is complex and riddled with headaches, but there are a number of other things to consider when asking yourself this question. First and foremost, you need to put the 15% topic aside and look at how important it is for your practice to be able to provide covered PT services to Medicare beneficiaries. Are you in an area where the vast majority of those seeking PT are over 64 years old? Could you keep your practice busy if you were not able to treat this part of the population? Remember, if you are not enrolled as either a Participating or a Non-Participating provider, you cannot provide beneficiaries with PT services that Medicare would normally cover.

You should also consider how important it is to you as a practitioner to be able to treat Medicare beneficiaries. I know some PTs who are not really concerned about having or not having that ability in their practice, and I know some who couldn’t imagine practicing PT if they were not allowed to treat Medicare-aged patients.

If you feel that you need to be able to treat Medicare beneficiaries, either financially or personally, but don’t want to wait for Medicare reimbursement (or denials), then being a Non-Par Provider might be a an option to consider regardless of the extra 15% you can bill.

Do you recommend new cash-based practice owners to become Non-Par Providers with Medicare since they can bill the extra 15%?

Again, the answer to whether or not to become a Non-Par Provider (rather than having no relationship at all with Medicare) really shouldn’t be about the 15% extra you can bill. If you think your practice can thrive without treating Medicare beneficiaries, you personally don’t mind being unable to treat them, and you would rather avoid the hassle of dealing with Medicare at all, then don’t enroll as a new practice. You will have to hire someone to do all the billing or take the time to do it yourself.

One scenario in which I think being a Non-Par Provider makes a lot of sense is the following: You are currently a Participating Provider with Medicare and you want to transition into more of a cash-based model, but still want to be able to treat Medicare beneficiaries. The infrastructure, staff, and processes are already in place to bill Medicare, so it makes sense if you still want to (or need to) treat this part of the population.

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Is being a Non-Participating Medicare Provider worth it? … It depends [click to tweet]

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