Must I Enroll In Medicare to Treat Medicare Beneficiaries?
I am often asked must physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs) in private practice enroll in the Medicare program if they want to treat Medicare beneficiaries for outpatient therapy services that are covered by the Medicare program? This then leads to a second question I am often asked. If PTs, OT’s and SLPs must enroll in the Medicare program, what is this non-participating provider status? Doesn’t this mean I don’t participate with Medicare, hence, I can charge the Medicare beneficiary cash for outpatient therapy services? How about services that are statutorily non-covered by the Medicare program; can I charge the Medicare beneficiary cash for those services?
In this article, I will answer the following questions:
- Must PTs, OTs and SLPs in private practice enroll in Medicare if they want to treat Medicare patients for covered services?
- What is the difference between enrolling as a participating provider and a non-participating provider with the Medicare program?
- If I enroll as a non-participating provider, does this allow me to bill Medicare beneficiaries cash for outpatient therapy services covered by the Medicare program?
- If I accept assignment on a claim, who does my Medicare Administrative Contractor send the payment to; me or the patient?
- If I do not accept assignment on a claim, who does my Medicare Administrative Contractor send the payment to; me or the patient?
- If I am enrolled in the Medicare program as a non-participating provider, must I accept assignment on a claim for a Medicare beneficiary enrolled in the QMB program?
- When can I bill Medicare beneficiaries cash for services I provide without submitting a claim to the Medicare program?
- If I am only going to provide services to a Medicare beneficiary that are statutorily noncovered by the Medicare program, must I enroll in Medicare?
Question #1
Must PTs, OTs and SLPs in private practice enroll in Medicare if they want to treat Medicare patients for covered outpatient therapy services?
Answer #1
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Question #2
What is the difference between enrolling as a participating provider and a non-participating provider with the Medicare program?
Answer #2
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Question #3
If I enroll as a non-participating provider, does this allow me to bill Medicare beneficiaries cash for outpatient therapy services covered by the Medicare program?
Answer #3
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Question #4
If I accept assignment on a claim, who does my Medicare Administrative Contractor (MAC) send the payment to; me or the patient?
Answer #4
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Question #5
If I do not accept assignment on a claim, who does my Medicare Administrative Contractor (MAC) send the payment to; me or the patient?
Answer #5
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Question #6
If I am enrolled in the Medicare program as a non-participating provider, must I accept assignment on a claim for a Medicare beneficiary enrolled in the QMB program?
Answer #6
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Question #7
When can I bill Medicare beneficiaries cash for services I provide without submitting a claim to the Medicare program?
Answer #7
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Question #8
If I am only going to provide services to a Medicare beneficiary that are statutorily noncovered by the Medicare program, must I enroll in Medicare?
Answer #8
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I know dozens of PT who accept cash payments from patients of all types including Medicare and are not enrolled with Medicare. They also do not submit claims.
They indicate that the legal review of their practices suggest there are no known cases of these services being considered in violation because there has been no payment received from Medicare thus nothing to recoup.
I’ll begin my response with an analogy. You and I both know people that drive above the posted speed limit, but are not caught by the police and given a ticket. Even though they were not “caught”, are they still guilty of breaking the law (speeding)? The answer is yes! Just because there are no known cases that have been brought before CMS does not mean it’s legal and okay to do. I know of large, powerful, reputable law firms in Washington D.C. that would disagree with the PTs and their attorneys in their interpretation that you mention. In addition, your professional association would disagree with your colleagues and their interpretation. I could go on, but this is not the forum to have this type of discussion.
Rick-
I want to make sure I’m understanding this…If a therapist is planning to ONLY provide cash services that are statutorily non-covered programs (wellness, fitness, senior athlete sports performance, etc) to individuals on Medicare, must they enroll in Medicare at all? Thanks.
No!
Hi Rick,
If we are a Medicare provider but the patient has a Medicare HMO plan that we are not in contract with, are we able to treat the patient on a cash basis? My gut is no. There is not a provider in the area that accepts the HMO plan. Thanks!!
Please read my Medicare Advantage FAQs at https://gawendaseminars.com/faq/medicare-advantage-plans/ to obtain the answer.