Participating Providers
This type of healthcare provider has agreed to accept Medicare and takes assignment, ultimately meaning that for healthcare services they will accept Medicare's approved amount as full payment.
Benefits For Patients
Lower out-of-pocket costs are the big benefit associated with participating providers that patients will experience. Typically these costs will total a maximum of 20% coinsurance or less for covered services. Billing is also easier for the patient as Medicare pays the insurance company direct and. Balance billing also does not exist for patients when using a participating provider. This means that beneficiaries are not billed anything more than the Medicare approved amount for a particular healthcare service.
Non-Participating Providers
Non-Participating providers have not accepted Medicare's approved amounts for different healthcare services and thus do not have a contract with Medicare or assignment.
Affect on Patients
If a patient elects to use a non-participating provider for a healthcare service they will most likely incur a higher costs for the service. These providers are able to charge an extra 15% on top of the Medicare designated amount of 20% for the service, this is called "limiting charge". Billing is also completely different for these providers as the patient may be required to pay for the service in full at the visit and then have to request reimbursement from Medicare on the back-end. Medicare may pay up to 80% of the reimbursement, excluding any excess charges. It is the patient's responsability to complete all of the reimbursement paperwork.
Opt-Out Providers
The final category to bring up is what are called opt-out providers, these providers have elected to opt out of Medicare entirely. The opt-out contract is a two year period where they will not work with Medicare at all and are able to charge their own rates entirely for healthcare services that they provide, making these providers the most expensive form of healthcare for beneficiaries. There are not many providers in this category, however it is worth noting that they do infact exist.
Contact a Poindexter representative today to learn more about the different provider types and where yours may fall.
