Medicare PAR vs. NonPAR Guidelines

by Trina Cuppett, CPC, CPC-H

Whether or not your provider participates in the Medicare program, it is important for all billing personnel to know and understand the guidelines pertaining to each.

CPB : Online Medical Billing Course

For instance are you aware that NonPARs (non participating providers) must also file claims on all Medicare patients whom they treat in the office?

  • NonPARs may choose to submit claim-by-claim assignments; however, there are restrictions that should be considered such as:
    • NonPAR’s must file all Medicare claims
    • A NonPAR is never allowed to “balance bill” a patient

When assignment is accepted on a claim, then the NonPAR may only collect the deductible or coinsurance amounts. These amounts are due at the time service is rendered for the assigned claim.

Participating providers have an agreement with Medicare to “accept assignment” on all Medicare claims, meaning that the provider will be receiving payment directly from Medicare.

  • In addition providers will receive a 5% higher fee schedule than NonPARs receive.
  • Providers also receive faster processing on all of their “assigned claims.”

Additionally, an annual publication is sent out to Medicare recipients which lists (regionally) participating providers, and there is a special message listed on the Medicare Summary Notice (received by Medicare recipients) to remind them how much money they would save by using a participating provider rather than a non participating provider.

All of the current and future changes in health care programs will require billing personnel, billing managers, and practice administrators and coding personnel to be thoroughly knowledgeable regarding insurance contracts.

Considering Medicare is the largest health insurer in the country at this time, it is more important than ever to understand the differences between PARs and NonPARs and how this affects your billing and revenue cycle as well as your compliance plan. Informed decisions regarding participation levels must be made with both providers and patients with Medicare coverage in the practice.

Understanding both federal and state insurance guidelines regarding insurance contracts, guidelines and the differences between participating and not participating in programs is essential to effective reimbursement. Understanding Medicare regulations becomes an absolute must since it is governed by federal laws and regulations.

Source: Understanding Health Insurance (9th Ed.)


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