Question:What is the Medicare deductible and rates for 2022? I know they are updated annually. Second question: I am a non-par provider; is there ever an instance in which I can charge more than Medicare allows?
You are correct: Every new year, Medicare updates rates and the deductible.
Other services such as exams, X-rays and therapies when performed by a doctor of chiropractic do not count toward the deductible. It is important to make patients aware of such and that while their total bill might be $100 for a single date of service in a chiropractic office, the amount applied toward the deductible may be only $40, as that is the allowed rate for a spinal manipulation service. The other excluded services do not count toward the deductible for Medicare.
Conversely, if a patient is seen by a medical provider, the covered services are much greater and the deductible could often be met within one visit. In a chiropractic setting, it may take 6-8 visits to meet the deductible. Be sure your patient is aware that if they have been to no other provider, their out-of-pocket payments applied to the deductible will take multiple visits when seeing a doctor of chiropractic.
Reduced Fees (for Now)
As far as fees, as of this writing, they are reduced from 2021. You will be able to find the specific fees published for your state under the respective Medicare Administrative Carrier (MAC); they may even vary by county.
The Medicare fee schedule has been in a state of flux and often what is initially published will change based on congressional budget approval. This often-last-minute change is made right at the start of the new year.
There were supposed to be reductions for 2021 that were not applied, but unfortunately, the 2022 fee schedule now includes some of the previously delayed cuts, and the 2 percent sequestration payment adjustment is back in effect beginning Jan. 1, 2022.
The result for 2022: Unless there is congressional action since this writing, the average Medicare fee cut will be 3.725 percent and payments may be reduced by an additional sequestration amount of 2 percent. This means you should see about a $1-4 reduction from 2021 fees.
Par vs. Non-Par
Medicare does publish three distinct fees; the allowances are dependent on being par (participating) or non-par (non-participating), and whether you do or do not accept assignment as a non-par provider.
If you are a par provider, the rate would be the rate you are paid with Medicare paying 80 percent and 20 percent by the patient. Note that this is only for spinal CMT; your regular rates would prevail for all other services.
If you are registered as non-par, you have a choice to accept or not accept assignment on a claim-by-claim basis. If you choose to not accept assignment, you may charge the patient the "limiting charge," which is approximately 10 percent above the par rate and represents the maximum allowed rate. There is still the requirement to bill Medicare, but the claim is unassigned and payment will go to the patient, as they have already paid the provider. Note that the amount the patient receives will be the non-par rate, which is the lowest and 15 percent below the limiting charge.
You may choose to not accept assignment as a non-par provider; you will then be paid at 80 percent of the non-par rate and the patient would balance 20 percent of that amount. 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.
Benefits of Participation
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 also are 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.
Can You Ever Charge More Than the Medicare Allowed Rate?
Finally, you also inquired about a time when you can charge more than the Medicare allowed rate. There is a time you may do so, but only when the services are non-covered, such as not medically necessary and the patient has been delivered an Advance Beneficiary Notice (ABN).Per the Medicare Claims Processing Manual, section 50.9:
A beneficiary who has been given a properly delivered ABN and agrees to pay may be held liable. The charge may be the healthcare provider or supplier's usual and customary fee for that item or service and is not limited to the Medicare fee schedule. If the beneficiary does not receive proper notice when required, s/he is relieved from liability.
In simplest terms, Medicare only controls the fee if it is a covered service. If it is normally covered, but not covered due to necessity and an ABN is used, it may be your regular rate.
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