Every year, between mid-November and December 31, physicians have the opportunity to change their Medicare participation status for the following year. Physicians have three choices with respect to their Medicare status:
- Participating Provider: By signing a participation agreement, the physician agrees to accept Medicare rates for all claims in exchange for various benefits provided by Medicare.
- Physicians who are already participating in Medicare do not need to take any action to continue participating.
- Physicians who wish to sign up for or terminate participation must do so during the open enrollment period with their decision postmarked no later than December 31, 2021, unless they are enrolling for the first time.
- Participating physicians are entitled to the full Medicare-approved charge for each service.
- Participating physicians receive certain benefits such as access to toll-free claims processing lines, and coordination of benefits with other insurers.
- Non-participating Provider: By declining to sign a participation agreement, the physician reserves the right to balance bill subject to limits imposed by Medicare.
- Nonparticipating physicians can accept assignment on a case-by-case basis.
- In nonassigned cases, the physician can balance bill the patient up to 115% of the Medicare-approved charge. The Medicare-approved charge for nonparticipating physicians is 95% of the full approved charge for assigned claims. Therefore, the most the physician can receive is 109.25% of the full Medicare approved charge.
- For non-assigned claims, the physician must submit the claim to Medicare but collects payment from the patient who receives the reimbursement from Medicare.
- MIPS payment adjustments are made on assigned claims but not on unassigned claims.
- Private Contracting: By signing an opt-out letter, the physician can opt out of Medicare entirely and enter into private contracts with Medicare beneficiaries by submitting an affidavit to the Centers for Medicare and Medicaid Services through their local Medicare Administrative Contractor.
- Physician agrees not to submit any claims or receive any payment from Medicare or Medicare Advantage plans for two years.
- Medicare charge limits do not apply.
- Affidavit automatically renews for two years unless cancelled by physician.
- The physician must enter into a written private contract with Medicare patients.
In assessing one’s Medicare participation status for 2022, it may be helpful to review the Advocacy Council Alert sent on November 5, which contains information on the 2022 reimbursement rates for allergy services.
The Advocacy Council – Advocating for Allergists and Their Patients.