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Participating and Non-Participating Medical Providers

What is the difference between Participating and Non-Participating Medical Providers?

Participating providers are Physicians and practitioners who register with Medicare as participating providers agree to accept assignment for all of their Medicare patients. Accepting assignment entails two conditions: agreeing to accept Medicare’s fee-schedule amount as payment-in-full for a given service and collecting Medicare’s portion directly from Medicare, rather than the patient.

Therefore, when Medicare patients see participating providers, they can be certain that these providers will not charge fees higher than Medicare’s published fee-schedule amount and that they will not face higher out-of-pocket liability than the maximum 20-percent coinsurance for most services.

The vast majority (96%) of providers who provide Medicare-covered services are participating providers. Non-participating providers are Physicians and practitioners that do not agree to accept assignment for all of their Medicare patients; instead they may choose — on a service-by-service basis— to charge Medicare patients higher fees, up to a certain limit.

When doing so, their Medicare patients are liable for higher cost sharing to cover the higher charges. This arrangement is called balance billing and means that the Medicare patient is financially responsible for the portion of the provider's charge that is in excess of Medicare’s assigned rate, in addition to standard applicable coinsurance and deductibles for Medicare services.

When non-participating providers do not accept assignment, they may not collect reimbursement from Medicare; rather, they bill the Medicare patient directly, typically up front at the time of service. Non-participating providers must submit claims to Medicare on behalf of their Medicare patients, but Medicare reimburses the patient, rather than the nonparticipating provider, for its portion of the covered charges.

As of 2011 only a small share (4%) of providers who provide Medicare-covered services are non-participating providers.

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