Medicare Participation Decision Deadline Extended to January 31, 2010

In light of the uncertainty surrounding the SGR and health reform, the Center for Medicare and Medicaid Services has extended the deadline for providers to determine their Medicare participation status for 2010.

Physicians who wish to change their participation status for 2010 will now have until January 31, 2010, to do so. The effective date of the decision will be January 1, 2010, retroactively if necessary. Participation decisions are binding for one year, unless physicians choose to opt out entirely. Once you opt out, you cannot opt back in for two years.

Physicians, as always, have three choices regarding Medicare: be a participating provider; be a nonparticipating provider; or opt out of Medicare entirely. A participating physician must accept Medicare-allowed charges as payment in full for all Medicare patients.

A nonparticipating provider can choose to accept or not accept assignment on Medicare claims on a claim-by-claim basis. Nonparticipating physician fees are 95% of participating physician fees. If you choose not to accept assignment, you can charge the patient 9.25% more than the amounts allowed in the participating physician fee schedule.

Physicians who opt out of Medicare are bound only by their private contracts with their patients. Medicare’s limiting charges do not apply to these contracts, but Medicare does specify that these contracts contain certain terms. When a physician enters into a private contract with a Medicare beneficiary, both the physician and patient agree not to bill Medicare for services provided under the contract.

For more information on physicians' Medicare participation options, see CMA ON-CALL document #0151, "Medicare Participation (and Nonparticipation) Options." ON-CALL documents are free to SDCMS-CMA members at CMA's website. Nonmembers can purchase ON-CALL documents for $2 per page at the CMA Bookstore.