Tis the Season to Update Your Medicare Participation Status

It is the time of the year when the National Provider Enrollment (NPE) Contractors will start mailing letters or post cards to all suppliers, notifying you of your ability to change your participation status with Medicare. This is an important reminder to suppliers to ensure their mailing address is updated in PECOS. A returned mail to the NPE Contractor may result in additional scrutiny which may result in deactivation or revocation. If a supplier changed any information, this must be timely reported to Medicare, ideally no later than 30 days from the change.

Medicare Participating Supplier

A Medicare participating supplier is one who voluntarily enters into an agreement to accept assignment for all services furnished to Medicare beneficiaries during a 12-month period, beginning January 1 of each year. This status is automatically renewed unless the supplier submits to the NPE Contractor in writing with their intention to change their participation status. When a supplier elects to become a participating supplier, it agrees to accept assignment on all claims for Medicare products and services and agrees to be paid Medicare allowed amount as full payment, less any unmet deductible and coinsurance.

Medicare Non-Participating Supplier

Suppliers who choose not to sign the participation contract are referred to as “Non-Participating Suppliers”. A nonparticipating supplier may choose to accept assignment on a claim by-claim basis except where CMS regulations require mandatory assignment (i.e., Medicare covered drugs, Indian Health Services). Accepting assignment means accepting the Medicare approved fee schedule. If a non-participating supplier does not accept assignment on a claim, the supplier can collect directly from the patient for the Medicare covered products and services and charge more than the Medicare allowed amount. Please note, suppliers are still required to submit the claim to Medicare on the patient’s behalf and Medicare will reimburse the patient it’s allowed amount less any unmet deductible and coinsurance.

Should I take Action?

Open enrollment forms (CMS-460, Medicare Participating DMEPOS Supplier Agreement) are mailed to all suppliers every November. If you are an existing nonparticipating supplier and want to become participating, then you must send the completed agreement form to the NPE contractor during open enrollment period. The form must be postmarked before December 31st of the current calendar year to be effective January 1st of the following calendar year.

If you are a participating supplier and want to become nonparticipating, you may request to become nonparticipating by sending the request to the NPE contractor on your company letterhead. The request must be postmarked and received before December 31st of the current year to become nonparticipating effective January 1st of the following year.

If you wish to retain your current participation status, then no further action is required. Only you can determine the appropriate action for your company. On October 15, 2024, Attorney Jeffrey S Baird, Esq. and ACU-Serve’s Chief Compliance Officer, Noel Neil conducted a webinar titled “Billing Non-Assigned: Steps to Replace Lost Income”. In the presentation we took a deep dive into participating and non-participating provider status. We also took a detailed look at billing unassigned claims. If you missed the webinar or are not familiar with unassigned billing, I highly recommend you watch the recorded webinar here.

If you have additional questions or concerns, please do not hesitate to contact Noel Neil directly at [email protected].