Medicare: The difference between opting out and non-participation

By Dava Stewart

First things first: Chiropractors cannot “opt out” of Medicare. They can choose to not participate, but that is different from opting out. DCs may also choose to not treat patients who have Medicare. The reasons that chiropractors cannot opt out are complex, and the difference between “participating” and “non-participating” practices comes down to how they bill patients covered by Medicare.

At first glance, it may seem as if opting out would be as simple as signing a form that says you don’t want anything to do with Medicare. However, in a guidance manual issued by the Centers for Medicare and Medicaid Services (CMS), the section that describes what you must agree to in order to opt out has nine bullet points and is preceded by an equally long section describing what private contracts with patients must include. Opting out is a convoluted and difficult process. Again, chiropractors cannot opt out, and of those care providers who are eligible to opt out, fewer than 2 percent choose to do so, according to the American Chiropractic Association (ACA).

DCs must either classify themselves as participating or non-participating in the Medicare program.

Participating (par) — According to the Medicare Participating Physician or Supplier agreement, participating means that you are “entering an agreement with the Medicare program to accept assignment of the Medicare Part B payment for all services for which the participant is eligible to accept assignment under the Medicare law and regulations and which are furnished while this agreement is in effect.”

Non-participating (non-par) — The CMS defines non-participating as: “A non-par provider is actually a provider involved in the Medicare program who has enrolled to be a Medicare provider but chooses to receive payment in a different method and amount than Medicare providers classified as participating. The non-par provider may receive reimbursement for rendered services directly from their Medicare patients. They submit a bill to Medicare so the beneficiary may be reimbursed for the portion of the charges for which Medicare is responsible.”

The difference, then, is in how you bill for your services. Simply put, if you are participating, your Medicare patients pay their co-insurance in your office, and you bill CMS for the remainder of the payment. If you are non-participating, your patient pays the full bill in your office and is later partially reimbursed by Medicare.

You will not avoid being audited by classifying yourself as non-participating. Reimbursement for non-participating providers is 5 percent less than for participating providers. Documentation requirements are the same for both participating and non-participating providers.

According to the ACA, “Non-participating doctors of chiropractic may be paid slightly more for services by choosing that status. The downside of this is that those extra dollars come from the patient, not the federal government.

“Participating providers have the advantage of being able to enter any fees they wish on the claim form when billing Medicare and the carrier will adjust the amount to reflect the current allowable fees determined by the fee schedule. This can be useful in times when the fee schedule levels are changing or uncertain and may ease the burden of locating the current values.

“Participating providers would also be listed in the MedParD (Medicare Participating Directory). This is a directory of all current participating providers and is sent to every Medicare beneficiary at the beginning of each year. In addition, participating providers always have the right to appeal. This is not true for non-par providers.”

The classification you choose will depend on several factors. Generally the CMS allows a six-week time period each year, from Nov. 15 to Dec. 31, during which DCs can change their classification. It makes sense to review your practice and options once a year.

Here are a few helpful resources: