Medicare Non Participating Doctors

There are three type of doctors regarding Medicare.  If you have Original Medicare only, or with a Medicare Supplement the following providers are available to you.

Participating Doctors (PAR)

Doctors who participate in Medicare agree to accept Medicare assignment (payment) for all claims for Medicare patients as payment in full.  They can charge up to 100% of the allowable Medicare fee schedule and not more.  Participating Doctors and other providers cannot bill the patient for any sum in excess of the Medicare allowable amounts.  For a list of doctors and suppliers in your area who participate in Medicare you can call 1-800-MEDICARE.

Non-Participating (Non PAR)

If the doctor is not a participating provider in the Medicare program, they have chosen not to accept the Medicare reimbursement fee schedule.  With this contract, it allows the doctors to charge their patient an additional 15% above what Medicare allows for any Part B services (outpatient).

The extra charge is called “Excess Charges” or “Limiting Charges.”  Excess Charges for Non-PAR doctors are set a 115% of the Medicare approved amount for non-PAR physicians.

However, because the Medicare approved amounts for Non-PAR physicians are reduced by 5% to 95% of the rate of PAR physicians, the 15% Excess Charge is actually only 9.25% above the Participating physician approved amounts for services.

Non Participating (non-PAR) doctors cannot charge more than 95% of the “Participating Provider” fee schedule.  Non Participating doctor fees are reduced by 5% for not participating in the Medicare Program, and the Excess Charges only apply to Medicare Part B coverage charges, although not for supplies or durable medical equipment.

Even though the doctor does not accept Medicare assignment, they are still required by law to submit the claim to Medicare.  For example; after the claim is processed, Medicare will reimburse the doctor 80% of the approved amount.  The balance of $35 (20% Part B coinsurance plus $15 Excess Charge is your out of pocket cost, assuming you do not have a Medicare Supplement plan to cover these charges.

Private Contracting Doctors

Physicians can choose to Opt-Out of the Medicare system all together.  Once they have opted out of Medicare they cannot submit any claims to Medicare for any of their patients for a period of 2 years.  For a doctor to see a Medicare beneficiary, the doctor must enter into a private contract that meets specific requirements, which must  be written and signed by you.

A doctor who has “opted-out” can charge their own rates and are not bound by the Medicare fee schedule.  If you have entered into an agreement with a doctor who has opted-out of Medicare, you will not be reimbursed by Medicare, or the Medicare Supplement policy.  You are responsible for all charges from that doctor, except those in need of “emergency” care, or urgent care.

Also, physicians who opt out cannot choose to opt out of Medicare for some Medicare beneficiaries but not others, or for some services and not others.

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John Conner

John Conner

Medicare Plan Options ... Medicare Supplement, Medicare Advantage, Medicare Part D Rx