In talking to DME suppliers all over the country, I find that many use the Medicare terms participation and assignment interchangeably. They are related – but not the same – so I thought a quick refresher on these two concepts might be useful to you and your billing staff.
Here is the most important thing to remember: participation status with Medicare dictates the ability to choose assignment.
What is a Participating Supplier?
Participating suppliers agree to accept claim assignment for all covered services provided to Medicare patients. Doing so means Medicare’s applicable allowable amount constitutes full compensation. Non-participating suppliers, on the other hand, may elect not to accept assignment and charge their patients their usual and customary charge amounts for services provided, even if those charges exceed the current Medicare fee schedule.
Suppliers must choose to participate in the Medicare program when enrolling in the Medicare program. It is not automatic.
Should DME Suppliers Participate?
Participation is a program level contract. That means one election applies to all branches and locations sharing the same tax identification number (TIN). Participation status is also uniform across all Medicare regions. Suppliers cannot, for example, elect to participate in Jurisdiction A and not Jurisdiction C.
Unlike physicians and other lines of business, non-participating DME suppliers are not subject to limiting charges or non-participation penalties. For these reasons, as well as the flexibility to choose assignment on a case-by-case basis, many DME suppliers elect not to participate.
There are, however, significant financial penalties for other non-participating healthcare providers like hospitals and physicians. For suppliers that share a TIN with providers that receive Medicare reimbursement through coverage benefits other than DME, I recommend speaking with a healthcare attorney to determine the implications for all affected lines of business before making a decision.
How do suppliers change their Medicare participation status?
Suppliers may change their participation status annually between November 15 and December 31 for the subsequent calendar year.
To change participation status, suppliers must send a letter on company letterhead requesting the change to the applicable National Provider Enrollment (NPE) contractor. No annual action is required for suppliers that do not wish to change their current enrollment status.
This, of course, is a conceptual overview. Next week, I will dive into the practical ramifications of assignment. In the meantime, give me a shout if you have questions about your participation status.