Question
QUESTION: Hello,
I have several providers who are not enrolled with Medicare, Medicare does not recognize the provider by NPI or PTAN. When these providers see Medicare patients they bill them their standard charge.
My question is, is there any legal obligation for these providers to submit a billing to Medicare and do they need to limit the amount collected to the limiting charge?
Thank you.
ANSWER: Hi James
Doctors that do not participate with Medicare. If you go to them, you are entering into a private contract that makes you responsible for paying their standard charge. They do not have to bill Medicare.
Doctors participating with Medicare and accept assignments: They bill Medicare, and will settle for the amount that Medicare approves. You pay any amount not covered by your plans.
Doctors that participate with Medicare, but do not accept assignment: They are allowed to charge an
extra 15% over the approved amount. That amount is called the limiting charge, so the doctor has a list of what he can charge for each billing code, You pay the limiting charge when you see the doctor. He sends the claim to Medicare who send you a check for their share. Your supplemental sends a check for their share, You end up paying about slightly more than 12% plus any deductibles.
Hope this helps.
John
---------- FOLLOW-UP ----------
QUESTION: John, your expertise is priceless, thank you so much for your quick and concise answer. I did some additional research and had just one follow up question.
One provider voluntarily terminated his Medicare ID and one was terminated for inactivity. Do either or both providers need to file and subsequently refile an Opt out affidavit?
Again, thank you so much for all of your help!
Answer
Hi again
I do not get too involved in provider problems. But, if they want to get back covering Medicare patients, they will have to sign a new provider contract with Medicare, That is for original Medicare. For the HMO, PPO and Advantage they do a contract with the plans.
But there is a Providers Manual that covers this, If you really want to check it all out====go to Medicare.gov====go to publications---go to Providers Manual===click on and read away
john
