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Medicare: Par, Non-Par, and Opt-out

Understanding what each term means



There's a lot of confusion around the different types of Medicare providers. What exactly do PAR, Non-PAR, and Opt-out mean? How do you choose which type of provider you want to be?


PAR and Non-PAR providers are both healthcare providers who accept Medicare insurance. However, there are some key differences between the two types of providers.


Participating (PAR) providers have signed a participating agreement with Medicare, which means they agree to accept Medicare's allowable charges as payment in full for all their Medicare patients. This means the patient will only be responsible for their deductible and 20% co-insurance, and Medicare will pay the rest. This also means that if Medicare says to write an amount, service, or procedure off because the provider charged more than the allowed amount, the provider has agreed to write it off. It is important to note that PAR providers are required to see all Medicare patients ( also called accept assignment), except in certain cases, such as when the patient is receiving emergency care. PAR providers must also bill directly to Medicare on behalf of the patient.


Non-participating (non-PAR) providers have not signed a participating agreement with Medicare. This means that they accept Medicare but do not accept Medicare's approved amounts for health care services. Non-PAR providers can choose to not see a patient (not accept the assignment) on a case-by-case basis. They are not required to see all Medicare patients like PAR providers.

Non-PAR providers can charge patients up to 15% more than Medicare's allowable charges, and the patient will be responsible for paying the difference. The 15% is in addition to the 20% co-insurance that the patient is already required to pay so a patient could potentially pay up to 35% more than the Medicare-allowed amount by seeing a Non-PAR provider. Some states put a limit on how much more a provider can charge than the allowed amount so it's important that each provider looks into what's allowed in their state. Non-PAR providers can also choose to bill patients directly, rather than billing Medicare.


Here's a breakdown of the two types of providers and how it affects the provider and patients.

Feature

PAR Provider

Non-PAR Provider

Accepts Medicare's allowable charges as payment in full

Yes

No

Can charge patients more than Medicare's allowable charges

No

Yes

Bills Medicare directly

Yes

Can choose to bill Medicare directly or bill patients directly

Patient pays deductible and 20% co-insurance only

Yes

The patient pays deductible, co-insurance, and any amount over Medicare's allowable charges

Opt-out Providers are providers that do not accept Medicare and sign an agreement to be excluded from the Medicare program. Once a provider chooses to opt out of Medicare they can not change their status for two years. If a provider wishes to enroll in Medicare Advantage plans they cannot opt out of Medicare. By opting out, the provider must have a private contract with Medicare patients stating that both parties will not bill Medicare for the services provided. The patient must understand that they are solely responsible for the amount owed to the provider.



Providers Eligible to Opt Out

  • Doctors of medicine

  • Doctors of osteopathy

  • Doctors of dental surgery or dental medicine

  • Doctors of podiatric medicine

  • Doctors of optometry

  • Physician assistants

  • Nurse practitioners

  • Clinical nurse specialists

  • Certified registered nurse anesthetists

  • Certified nurse midwives

  • Clinical psychologists

  • Clinical social workers

  • Registered dieticians and nutrition professionals

Providers NOT Eligible to Opt Out

  • Groups/Organizations

  • Part A enrollments

  • Chiropractor

  • Anesthesiologist assistant

  • Speech Language Pathologist

  • Physical Therapists

  • Occupational Therapists

  • Any specialty not eligible to enroll in Medicare

Each choice will set a practice down a different path so it's crucial that owners and providers are aware of how this choice can impact them and the success of their practice. Educated decisions will build solid foundations so if you are uncertain about which choice best suits your goals, contact us today for a consultation.

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