What participating provider will Get - Incentives

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



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