Understand how physicians who are identified by the Medicare program as non-participating may still provide care for Medicare beneficiaries and receive payment by the program. Learn how Medicare sets different payment levels for services provided by participating and non-participating physicians.
The downside to being a non-participating physician is that the maximum Medicare payment amount is set at 95% of the amount paid for the same service when furnished by a participating physician. The positive aspect of non-participation is the ability to bill above the RVS amount. While balance billing does increase a non-participating physician’s total payment, it is limited to 115% of the allowed amount. Consider the following chart:
|RVS Participating Allowed Amount||$100||$500||$800|
|Balance Billing Amount||0||0||0|
|Maximum Participating Payment||$100||$500||$800|
|RVS Non-Participating Allowed Amount||$95||$475||$760|
|Balance Billing Amount||14.25||71.25||114|
|Maximum Non-Participating Payment||$109.25||$546.25||$874|
Most claims for physician services are submitted on an assigned basis, and participating physicians submit the vast majority of these claims.