November 09, 2022
It’s that time of year again – time for doctors to decide if they want to make any changes to their Medicare membership status. Physicians have until December 31, 2022 to make changes for the 2023 membership year. The effective date of any changes will be January 1, 2023.
In making the decision for the 2023 Enrollment Year, physicians should be aware that the Centers for Medicare and Medicaid Services (CMS) recently released the final rule and policies for the next year. The price list has not yet been published.
As always, physicians have three choices regarding Medicare: be a participating provider; be a non-participating supplier; or remove yourself from Medicare altogether. Details on each of the three participation options are as follows:
A participating physician must accept Medicare-authorized charges as full payment for all Medicare patients. A participating supplier receives 5% more reimbursement than a non-participating supplier.
A non-participating supplier may make award decisions on a case-by-case basis and bill patients more than Medicare’s allowance for unassigned claims. The fees of non-participating physicians represent 95% of the fees of participating physicians. If you choose not to accept the assignment, you may charge the patient 9.25% more than the amounts allowed in the Participating Physician Fee Schedule (equivalent to 15% of the non-participating fee).
Doctors who retire Medicare are only bound by their private contracts with their patients. Medicare’s limit charges do not apply to these contracts, but Medicare specifies that these contracts contain certain conditions. When a physician enters into a private contract with a Medicare beneficiary, the physician and patient agree not to bill Medicare for services provided under the contract. As a result of the 2015 Medicare Access and CHIP Reauthorization Action (MACRA), validated opt-out affidavits signed on or after June 16, 2015 will be automatically renewed two years after the effective date.
Physicians wishing to change their participation status for 2023 must submit a Medicare Participating Physician or Provider Agreement (CMS-460) to Noridian, the California Medicare contractor, postmarked by December 31, 2022. The participation agreement will automatically renew each year. However, if there is a change of name or EIN (tax identification number), you will need to complete a new Participation Agreement.
There is also information about physicians’ Medicare participation options in the California Medical Association (CMA) Health Law Library: Document #7209, “Medicare Participation (and Nonparticipation) Options.” Health Law Library documents are free for members at cmadocs.org/health-law-library. Non-members can purchase documents for $2 per page.
Click here for more information on open enrollment on the Noridian website.
Contact: Cheryl Bradley, (916) 551-2862 or [email protected]