CMS Medicare PAR vs NonPar for Physical Therapists

Описание: #Medicarebilling #medicareforPT #medicareforOT #medicareforSLP
Medicare Policy Manual CMS Chapter 15: https://www.cms.gov/Regulations-and-G...

CMS 460: https://www.cms.gov/Medicare/CMS-Form...

Medicare.gov article: https://www.medicare.gov/your-medicar...

CMS PAR:
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 MEDPARD (Medicare Participating Physicians and Suppliers Directory)
Reimbursement is 5 percent higher than the non-participating amount.
Medigap information is transferred.
Patient referral service by hospital
NonPar:
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

If the provider performs elective surgery costing more than $500, the beneficiary must be notified in writing of the expected financial responsibility.

Cannot bill the patient more than the limiting charge on non-assigned claims. (DC, DE, MD, NJ, City of Alexandria, VA, Counties of Arlington and Fairfax in VA)

Pennsylvania’s Medicare Overcharge Measure prevents non-participating physicians from charging patients more than the Medicare allowance. Therefore, PA providers cannot bill the patient more than the Medicare approved amount on non-assigned claims.

Beneficiary receives payment on non-assigned claims

Mandatory claims submission applies.

Clinical laboratory services and drugs and biologicals must be billed as assigned.

Approved amount is 5 percent less than participating — even if assignment is accepted on the claim.

Medigap information is not transferred.