by Wyn Staheli, Director of Research
March 25th, 2019
Even though we may think we truly understand what it means to be a participating provider, Medicare doesn’t quite work the way that other insurance plans do. Far too many providers do not understand the difference and get into hot water. To further complicate matters, the rules are different for Part A/B versus Part C/D. Also, do not confuse ‘out of network’ with participation status. Perhaps the time has come for us to start using different words to describe a provider’s status with a third-party payer. Using “in network” instead of “participating” to refer to situations where you have gone through a credentialing type process with the payer and using “Out of network” instead of “non-participating”.
Medicare Part A or Part B
Medicare Part A and Part B are known as ‘traditional’ Medicare plans. For Medicare Part A and Part B, participation status has to do with your payment status — not your enrollment status.
It is critical for you to understand that unless you are enrolled with Medicare, you can NOT treat a Medicare beneficiary — period. You must go through Medicare’s provider enrollment process, including revalidation every five years, if you want to treat a patient enrolled in Medicare.
Medicare Part C or Part D
Medicare Part C, also known as Medicare Advantage (MA), and Part D have always been a little different than traditional Medicare when it comes to rules and that also applies to this issue of enrollment. There must have been some issues or concerns about enrollment requirements for providers because Final Rule CMS-4182-F, which became effective on June 15, 2018, states:
This final rule will rescind current regulatory provisions that require prescribers of Part D drugs and providers of MA services and items to enroll in Medicare in order for the Part D drug or MA service or item to be covered.
This statement makes it clear that you do NOT have to be officially enrolled with Medicare to provide these services.
This demonstrates why insurance verification is such a critical task. You must know what type of Medicare plan the patient has because traditional Medicare and MA have different requirements. Annually checking their plan status is also essential because they could switch from a MA plan back to traditional Medicare and you could find yourself in trouble.