Practice Management Alert

Question: How do you submit claims to Medicare for a non-par provider? All my physicians have been par, and I have a new one that is non-par, but wants to treat a Medicare patient.

Colorado Subscriber

Answer: You will have to submit a claim whether the physician is par or non-par with Medicare. The billing difference when the physician is non-par is that you should collect up front from the patient. You-ll collect the limiting charge. If you do not collect from the patient and accept assignment from Medicare, you will receive five percent less than the Medicare participating fee schedule.

Remember: Do not check "accept assignment" on the CMS 1500 form. Otherwise the submittal process is the same as your process for submitting for a participating physician. Because you did not accept assignment and were paid by the patient, Medicare will pay the patient.

Tip: Now, if your physician sees a patient in the hospital and you therefore do not collect from the patient at the time of service, you can submit a claim "accepting assignment." This way you do not have to bill the patient more than his 20-percent copay and deductible. However, if you do this, you will not be allowed the limiting charge. Instead, you will be allowed 5 percent below the participating charge. If you submit not accepting assignment, the patient will get the Medicare check, and you will have to be diligent in billing, following up, and collecting from the Medicare patient. So, if your non-participating provider sees a lot of inpatient patients, where you cannot collect payment upfront, you will ultimately be paid less income or have to take the risk of bad debt and wait for the patient to pay the practice after the patient has been paid by Medicare.