Medicare law provides the following incentives encouraging providers/suppliers to enter into a participation agreement:
• Financial benefits for participating provider/supplier - Medicare allowances for services billed by participating provider/supplier are calculated 5% higher than that for a non-participating provider/supplier. The fee schedule is available on the NHIC website at http://www.medicarenhic.com
• Directories - NHIC offers the Medicare Participating Physician/Supplier Directory (MEDPARD) which contains the name, address, and specialty of each participating provider, at http://www.medicarenhic.co/bene/participating.shtml
• Hospital referrals - Hospital staff referring a Medicare patient to a non-participating provider/supplier for further care on an outpatient basis, where practical, must also identify a participating provider/supplier for the patient.
• Beneficiary referrals - Medicare beneficiaries are given the name, address, specialty and telephone number of participating provider/supplier in their area (via Medicare beneficiary toll-free telephone lines).
• Reminders to beneficiaries - The Medicare Summary Notice (MSN) for non-assigned claims includes a message reminding beneficiaries of the participation program.
• Secondary insurance crossovers – Transfer of paid claim information is provided to secondary insurers (e.g., Medigap plans).
Examples of Medicare allowances for services billed by participating provider/supplier:
Participating Provider Reimbursement
Provider bills Medcare................................................ $115.00
Medicare allows (PAR AMT)......................................... $90.00
Medicare pays (80%) ................................................ $72.00
Coinsurance (20%).................................................... $18.00
Non-Participating Provider Reimbursement
(Provider does not accept assignment on the claim)
Limiting Charge...................................................... $100.48
Provider bills Medicare ........................................... $100.48
Medicare allows (NON PAR AMT).............................. $87.37
Medicare pays (80%) to the patient......................... $69.90
Coinsurance (20%)................................................ $17.47
• Hospital referrals - Hospital staff referring a Medicare patient to a non-participating provider/supplier for further care on an outpatient basis, where practical, must also identify a participating provider/supplier for the patient.
• Beneficiary referrals - Medicare beneficiaries are given the name, address, specialty and telephone number of participating provider/supplier in their area (via Medicare beneficiary toll-free telephone lines).
• Reminders to beneficiaries - The Medicare Summary Notice (MSN) for non-assigned claims includes a message reminding beneficiaries of the participation program.
• Secondary insurance crossovers – Transfer of paid claim information is provided to secondary insurers (e.g., Medigap plans).
Examples of Medicare allowances for services billed by participating provider/supplier:
Participating Provider Reimbursement
Provider bills Medcare................................................ $115.00
Medicare allows (PAR AMT)......................................... $90.00
Medicare pays (80%) ................................................ $72.00
Coinsurance (20%).................................................... $18.00
Non-Participating Provider Reimbursement
(Provider does not accept assignment on the claim)
Limiting Charge...................................................... $100.48
Provider bills Medicare ........................................... $100.48
Medicare allows (NON PAR AMT).............................. $87.37
Medicare pays (80%) to the patient......................... $69.90
Coinsurance (20%)................................................ $17.47
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