Participating vs Non-Participating Provider with Medicare: What’s the Difference

October 8, 2018
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Rick Gawenda
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Last week, I published an article titled “How to Bill Medicare for a Therapist Not Yet Credentialed“. This article then led to readers asking 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? The answer is yes. PTs, OTs and SLPs in private practice must enroll in the Medicare program if they want to treat Medicare beneficiaries for services that would be covered by the Medicare program. In addition, once they enroll in the Medicare program, PTs, OTs and SLPs in private practices do not have the option to opt out if they want to treat Medicare beneficiaries for services that would be covered by the Medicare program. They must remain enrolled in the Medicare program.

This then leads to a second question I am often asked. If PTs, OT’s and SLPs in private practice 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? The answer is no. In this article, I will explain the difference between being a participating provider or a nonparticipating provider with Medicare, which one you are automatically enrolled in when you become a Medicare provider unless you complete an additional form and the pros and cons of each.

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  1. This article was extremely helpful! Thank you.
    What about a case where the therapist is a Medicare provider, but providing a non-covered service, ie myofascial release or fitness programs?

    1. Myofascial release is considered manual therapy. If a service is statutorily non-covered, then you can collect cash from the Medicare beneficiary and no ABN is required.