What does it mean if a doctor is a “non-participating provider” for Medicare?
Becky turned 65 recently. She has Medicare and a Medicare supplement, and she is looking for a primary care doctor. She called Desert Sage Internal Medicine in Oro Valley and asked if the doctors take Medicare. She did not understand the answer she got.
“We are non-participating for Medicare, but we have many Medicare patients”, is what Betty was told by the person who answered the phone at Desert Sage Internal Medicine.
I called Desert Sage Internal Medicine to get clarification on exactly what “non-participating” means. According to the person I spoke with, this group of doctors does not participate in the Medicare electronic billing system. Instead, patients with Medicare pay their bill when they see their doctor. The bill is for the “Medicare-allowed amount” and does not include any additional charges.
Desert Sage Internal Medicine then sends the bill (stamped “paid”) to Medicare and to the patient’s Medicare supplement (if she has one). Medicare will reimburse the patient for 80% of the bill. The patient’s Medicare supplement will reimburse the patient for the percentage of the bill it should pay.
I told Becky she should find a doctor who will bill Medicare and not her, especially since Becky is paying for a Medicare supplement Plan F. Most doctors bill Medicare electronically. Medicare will then get the supplement to pay its part, and Becky will have no bills. And she won’t be waiting to get reimbursed for her medical bills.
I checked the Medicare.gov website to get some “official” information about “non-participating” providers. Here is what I found:
Non-participating providers haven’t signed an agreement to accept assignment for all Medicare-covered services, but they can still choose to accept assignment for individual services. These providers are called “non-participating.”
Here’s what happens if your doctor, provider, or supplier doesn’t accept assignment:
- You might have to pay the entire charge at the time of service. Your doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare-covered services they provide to you.
- They can’t charge you for submitting a claim. If they don’t submit the Medicare claim once you ask them to, call 1‑800‑MEDICARE.
- In some cases, you might have to submit your own claim to Medicare using Form CMS-1490S to get paid back.
- They can charge you more than the Medicare-approved amount, but there’s a limit called “the limiting charge.” The provider can only charge you up to 15% over the amount that non-participating providers are paid. Non-participating providers are paid 95% of the fee schedule amount.
The limiting charge applies only to certain Medicare-covered services and doesn’t apply to some supplies and durable medical equipment.
Not sure if your doctor is covered by Medicare?
“Non-participating” is very different from “opting out of Medicare“, and I recently posted information about doctors opting out of Medicare.