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  • Medicare Provider Participation and Non-Participation

Medicare Provider Participation and Non-Participation 

June 14, 2023

Physical, occupational, and speech therapists can be participation or non-participating providers in Medicare.  PTs, OTs, and SLPs can also not enroll in Medicare at all but cannot be “opt-out providers” so the current rules are a little grey, more on this below.

Participating Providers

A participating provider is one who voluntarily and in advance enters into an agreement in writing to provide all covered services for all Medicare Part B beneficiaries on an assigned basis:

    • Agrees to accept Medicare-approved amount as payment in full;
    • May not collect more than applicable deductible and coinsurance for covered services from patient;
    • Payment for non-covered services may also be collected;
    • Charges are not subject to limiting charge;
    • Medicare payment paid directly to the provider;
    • Mandatory claims submission applies;
    • Placement in Medicare Participating Physicians and Suppliers Directory (MEDPARD);
    • Reimbursement is 5 percent higher than the non-participating amount;
    • Medigap information is transferred; and
    • Patient referral service by hospital

Non-Participating Providers

A non-participating provider has not entered into an agreement to accept assignment on all Medicare claims:

    • Can elect to accept assignment or not accept assignment on a claim-by-claim basis;
    • Cannot bill the patient more than the limiting charge on non-assigned claims;
    • Beneficiary receives payment on non-assigned claims;
    • Mandatory claims submission applies;
    • Approved amount is 5 percent less than participating — even if assignment is accepted on the claim; and
    • Medigap information is not transferred.

Opt-Out Providers

Physician/Practitioners can choose to be opt-out providers which means they are not enrolled in Medicare, cannot bill Medicare, and instead must enter into a private contract with Medicare beneficiaries in order to collect payment directly from the beneficiary.  The physician/practitioner cannot choose to opt-out of Medicare for some Medicare beneficiaries but not others; or for some services but not others.  The physician/practitioner who chooses to opt-out of Medicare may provide covered care to Medicare beneficiaries only through private contracts.

Physical therapists in independent practice, occupational therapists and speech therapists in independent practice cannot opt out because they are not within the opt out law’s definition of either a “physician” or “practitioner”.

Unfortunately, Medicare has not been clear on the obligations of therapists who are not enrolled in Medicare as either participating or non-participating providers. 

Medicare does provide us with this language:

    • The only situation in which non-opt-out physicians or practitioners, or other suppliers, are not required to submit claims to Medicare for covered services is where a beneficiary or the beneficiary’s legal representative refuses, of his/her own free will, to authorize the submission of a bill to Medicare.  However, the limits on what the physician, practitioner, or other supplier may collect from the beneficiary continue to apply to charges for the covered service, notwithstanding the absence of a claim to Medicare.
    • In some circumstances, a non-opt-out physician/practitioner, or other supplier, is required to provide an Advance Beneficiary Notice of Noncoverage (ABN) to the beneficiary prior to rendering an item or service that is usually covered by Medicare but may not be covered in this particular case.  The ABN notifies the beneficiary that Medicare will likely deny the claim and prompts the beneficiary to choose whether or not he/she will accept liability for the full cost of the services if Medicare does not pay.  The beneficiary also indicates on the ABN whether or not a claim should be submitted to Medicare.  Providers and suppliers must follow the beneficiary’s directive for claim submission as indicated on the ABN.  Providers and suppliers will not violate the mandatory claim submission rules of §1848(g)(4) of the Social Security Act when a claim is not submitted per a beneficiary’s written request on an ABN.  Where a valid ABN is given and a claim is submitted, subsequent denial of the claim relieves the non-opt-out physician/practitioner, or other supplier, of the limitations on charges that would apply if the services were covered.

The language above indicates that non-opt-out therapists should use an ABN form to inform their clients that they are not enrolled in Medicare and that the client will be responsible for payment.  This is especially important when Medicare would otherwise cover the therapy services. 

For services that Medicare never covers such as wellness or general exercise, an ABN is voluntary, however, it is still a good idea to use one because it puts the client on notice that they are responsible for payment and why.     

See our Medicare ABN section for detailed instructions on how to use an ABN form.

Reference

Centers for Medicare and Medicaid.  Medicare Benefit Manual Ch. 15 § 40

Novitas Solutions - Participating Provider Versus Non-Participating Provider

About Us

Zachary Edgar JD, LLM is the managing partner for Therapy Comply.  Zachary is a healthcare attorney that specializes in federal and state healthcare regulatory issues particularly for physical, occupational, and speech therapy practices.  

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