Practice Management Alert

Hint: Credentials matter.

Check out these true or false questions to test your knowledge on which providers can bill for Medicare payment.

Myth 1: Licensed Practitioners Can Bill Medicare Immediately

Clinicians must enroll with Medicare before submitting claims, said Patsy Schwenk of Medicare Administrative Contractor (MAC) CGS in a “Medicare Basics” webinar. To become a Medicare provider, physicians who hold the following credentials can enroll: Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), Doctor of Podiatric Medicine (DPM), and Doctor of Chiropractic (DC). In addition, “nonphysician practitioners, such as physician assistants, nurse practitioners, social workers, physical therapists, occupational therapists, audiologists, speech-language pathologists, and others can also enroll.”

Plus: There are suppliers like ambulance companies, durable medical equipment suppliers, independent diagnostic testing facilities, and others that can enroll in the Medicare program. However, registered nurses (RN) and licensed practical nurse (LPN) do not get Medicare numbers.

“Before enrolling into Medicare, you have to obtain a national provider identifier [NPI], which you can apply for online,” she adds.

Myth 2: Only Participating Providers Can Bill Medicare

When you become a Medicare provider, you decide whether you want to participate in Medicare or not — but that doesn’t mean you’re barred from billing the Medicare program if you decide not to participate.

If you say that you want to participate, “you are agreeing to accept Medicare’s fee schedule as payment in full,” cautions Schwenk. “So if Medicare’s allowed amount is $100, Medicare will pay $80 and the patient would pay $20 coinsurance and that’s all you will collect.”

There are some advantages to participating with Medicare, she said. For instance, you get the full fee schedule amount, you’re set up for automatic crossover (the MAC processes the claim and sends the information to the supplemental insurers), and you’re included in the MEDPARD directory, where patients can look for providers in their area who accept assignment. About 95 percent of providers do participate in Medicare, she continues.

Non-par: However, you can choose to be a non-par provider and not participate. If you are a non-par provider, you can still see Medicare patients and you still need to send in the Medicare claims on the patient’s behalf.

“Participating and non-participating providers must follow the mandatory claim submission laws, which means you must submit the claim for payment to Medicare,” Shwenk notes. If you are a non-par provider, you can accept assignment on a claim-by-claim basis, but non-par providers do receive a 5 percent reduction in the fee schedule amount. “So in my previous example where I said if the fee schedule pays $100, a non-par provider would be starting out at just $95 instead,” she says.