QUESTION: Is there any occasion that I can bill a Medicare patient for an amount greater than the Medicare-allowed charges for spinal CMT? I am also thinking of transitioning to an all-cash practice; if I decide to no longer be part of Medicare (par or non-par), can I still treat a Medicare patient for cash?
Medicare does, in fact, maintain a maximum allowed rate providers may collect for covered Medicare services.
Par vs. Non-Par Status and Reimbursement Rates
Providers registered as "par" providers (participating) must only collect the "par" amount and always accept assignment for claims when care is medically necessary. In this case, Medicare pays 80 percent of the allowed rate and the patient is liable for 20 percent.
However, a "non-par" provider has two options. If not accepting the assignment and the patient is paying at the time of service or out of pocket, the provider may charge the "limiting charge," which is the highest allowed amount by Medicare for covered services.
But if accepting assignment, the non-par provider is limited to the non-par amount. This amount is the least of all three Medicare allowed rates – Medicare pays 80 percent and the patient is liable for 20 percent.
Based on these protocols, clearly a provider who is non-par, but accepting assignment on a majority of claims, is losing money and should become a par provider. Otherwise, the provider is following a protocol that simply pays less.
If you are accepting assignment on a bulk of claims as non-par, you would generate higher reimbursement by being par, as the par amount is higher than the non-par rate. If accepting assignment anyway, you may also get the higher reimbursement.
Specifically, the limiting charge for non-par providers is 15 percent higher than the par amount. (Note that in some states, such as New York, the limiting charge is only 5 percent higher.) The non-par rate is 5 percent below the par rate.
Is It Possible to Charge Above the Medicare Amount?
Can you charge more than the Medicare amount? The answer is yes .... but only in a very specific situation. If the spinal manipulation service is determined as not covered by Medicare (maintenance or another scenario, such as a non-covered service via diagnosis or a similar situation), as long as you are providing an Advance Beneficiary Notice (ABN) that the service is not covered, you may charge the Medicare patient your regular rate.
This rule is defined in the Medicare Claims Processing Manual, Section 50.7.3: "A beneficiary who has been given a properly written and delivered ABN and agrees to pay may be held liable. The charge may be the supplier/provider's usual and customary fee for that item or service and is not limited to the Medicare fee schedule."
This makes it clear that when the CMT is maintenance or otherwise not covered by Medicare, you may choose to charge the Medicare patient your regular fee for spinal CMT and are not limited to the Medicare rates. You must make the patient aware of the fees prior to the delivery of the services and do so on an ABN.
Treating Medicare Patients in an All-Cash Practice
This is much more complex and unfortunately, the answer is not one most chiropractors want to hear. If you want to operate a 100-percent cash practice and still treat Medicare patients, you need to be a registered provider of Medicare. The reason: a federal requirement that covered services for Medicare must be billed to Medicare.
Thus, even though you are running an all-cash practice, you must still send a claim to Medicare and when registered as non-par, you may have the patient pay at the time of the visit. However, it will be the limiting charge in cash when it is a covered service by Medicare. The patient will receive 80 percent of the non-par rate from Medicare. When it is maintenance or non-covered, you may charge at that time, in cash, your regular rate when you have indicated such on the ABN.
If you are registered as a par provider, you cannot be 100-percent cash, as you cannot charge the patient at the time of service unless it is a maintenance visit and there is an ABN. Otherwise, you must accept an assignment and await payment from Medicare.
Key Points to Remember
- If you wish to operate a 100-percent cash practice and still treat Medicare patients, the only option is to register with Medicare as non-par.
- Keep in mind that non-par (non-participating) means you are registered with Medicare under that designation.
- If you choose not to register with Medicare (par or non-par), you simply cannot see a Medicare patient for cash.
- When it comes to audits / reviews of claims, it makes no difference whether a provider is par or non-par.
- Note that the term opt out does not apply to doctors of chiropractic and only to physicians (MDs).
Editor's Note: Feel free to submit billing questions to Mr. Collins at
. Your question may be the subject of a future column.
Click here for more information about Samuel A. Collins.