July 17th, 2015
Institutional providers (those that bill Fiscal Intermediaries (FIs)) are paid direct by the FI. In contrast, physicians, practitioners, and suppliers that bill the carrier may choose to enter into a participation agreement.
Carrier “Participating Providers” are paid at 100 percent of the physician fee schedule and must accept assignment (must accept program payment as payment in full, except for any unmet deductible and coinsurance). “Non-participating providers” are paid at 95 percent of the physician fee schedule and may accept assignment on a claim-by-claim basis.
Physicians and suppliers enrolled in the Medicare program under the Form CMS-855 process do not have to sign a “Medicare Participating Physician or Supplier Agreement” in order to bill Medicare and receive payment. However, there is a 5 percent reduction in the Medicare approved amounts if the physician or his/her reassignee does not participate. Participation is an election that is optional to suppliers, even those that have to bill assigned.
Also, regardless of participation, some suppliers and practitioner types are required to accept assignment. This is covered in the instructions in later chapters for each service type.