You are a licensed Audiologist, what do you need to know about Medicare? You’ll need to know a lot, but let’s start with your status within Medicare. Status within Medicare is divided into 3 categories:
Participating providers accept assignment from Medicare. The provider bills Medicare at their usual and customary fee; however, Medicare pays the provider 80% of the “allowed amount” for each CPT code. Patients are responsible for 20% of the allowed amount and this 20% should not be waived. The provider cannot bill patients for amounts in excess of the allowed amount and must write off the difference between the allowed amount and usual and customary fees.
Non-Participating Providers do in fact participate with Medicare. Non-participating providers generally do not accept assignment on a regular basis; however, they can choose to accept assignment on a case-by-case basis and be reimbursed at the non-par level. Non-par providers must also bill Medicare, but Medicare reimburses the patient versus the provider. The amount patients receive from Medicare will be 5% less than the par-allowed amount and the patient pays the provider for services rendered. The amount you can charge must be at or under the “limiting fee”.
Providers Who Opt-Out
The third choice is to “opt-out”. The provider may become a private contracting physician, agreeing to bill patients directly and forego any payments from Medicare to their patients or themselves. Once physicians have opted out of Medicare, they cannot submit claims to Medicare for any of their patients for a two-year period.
Audiologists and Medicare
If you are an Audiologist, you have two choices regarding Medicare. You can be a participating provider or a non-participating provider. Opting out is not a choice for Audiologists.
Your status either participating or non-participating with Medicare will dictate who you bill, how much you collect for a given procedure and the responsible party. If a Medicare beneficiary requests that an audiologist bill Medicare for the services performed, that audiologist is legally required to do so per the Mandatory Claims Statute.
In a nutshell if you’re an Audiologist you’re either a participating provider with Medicare or a non-participating provider with Medicare…pick one.