Medicare Provider Participation Decisions Due By December 31st

Medicare providers have until December 31st of each year to make changes to their participation decisions.  The Participation Agreement (CMS460) is originally filed with Medicare provider enrollment application and is effective through December 31 of each year.  The Agreement automatically renews each year for the coming 12 months unless the provider notifies the appropriate Medicare contractor(s) that the provider wishes to terminate the Agreement at the end of the current term, or CMS finds cause to terminate the provider from the program.

In cases of a privately owned medical group that bills for physician, and non-physician provider, services in the name of the entity, one Participation Agreement binds all providers with respect to services furnished for the group.  Therefore updates at the group level affect all providers and new providers in the group don’t necessarily need to submit a Participation Agreement with their initial enrollment application.

What Does Medicare Provider Participation Mean To You?

When a provider elects to participate in the Medicare program, s/he agrees to accept Medicare reimbursement rates as payment in full for services rendered to Medicare beneficiaries.  Medicare reimburses Participating providers at 100% of the Medicare fee schedule, 80% coming from Medicare and 20% from the patient.  Clean claims are typically paid within 14 days of receipt.

If a provider elects not to participation in the Medicare program, s/he has the option to accept assignment on claims.  If a non-par provider accepts assignment, then Medicare will pay the provider 95% of the Medicare allowable with 80% coming from Medicare and 20% from the patient.  If a non-par provider does not accept assignment, then Medicare will pay the patient directly and the provider must bill and collect from the patient for services rendered.  When assignment is not accepted, providers can bill the patient up to the limiting charge of 115% of Medicare.  In theory, you can make more money as a non-par provider; but there are certain challenges to collecting from patients that should be weighed when making the decision.  Cash flow also comes into play because collections from patients will certainly be slower than collections from a Medicare contractor for a clean claim.

Obtain a CMS460 Medicare Provider Participation Agreement here or visit the CMS website for more information.