I receive many questions about insurance and Medicare signup. In a recent answer, I provided more detail on Medicare signup for chiropractors and "participating" physician status:
First, any health care provider, including chiropractors, that provides any services to someone with Medicare coverage must send in a "bill" to Medicare, even if the services are not covered. You're correct that only adjustments are covered and only for "active" relief of specific conditions . Makes no difference to Medicare if it's covered or not. They still need the paperwork if you're caring for someone who is Medicare-eligible. Crazy, I know.
So you do need an NPI and you need to be signed up for your practice to be a Medicare provider (855i or 855b). Even if you never saw a Medicare patient, it would be a good idea to get this in place, since many insurance providers use the Medicare NPI as part of their own process.
Second, when you sign up for Medicare, you can decide if you want to become a "participating" provider. .
Here are the relevant facts about being a participating (PAR) physician:
1. PAR providers receive the "full" amount of the benefit Medicare
pays; non-PAR providers received 95%. Providers receive "direct and
timely" reimbursement from Medicare; non-participating providers may
collect from the patient or collect from Medicare. The doctor can bill
Medicare whatever he/she feels is reasonable for the service, as long
as Medicare patients are not billed more than non-Medicare patients.
2. PAR providers also have "one-stop" billing, since Medicare forwards
claims to secondary insurers if this information is provided on the
claim form.
Since most chiropractic care is not covered by Medicare, most chiropractors choose to be non-participating, Non-PAR doctors can't charge what they want for covered services; the charge is limited to what Medicare considers reasonable, if you don't accept assignment (this is explained in the next paragraph). If you don't want to be a PAR doctor, you don't need to do anything. If you want to participate, you must elect to do so, either immediately after you become a provider or during an enrollment period. The form to use is CMS-460.
Third, (I warned you this was complicated!), there is the question of accepting assignment; that is, whether you want to get the money from the patient or from Medicare. If you are a PAR doctor, you must accept assignment (that is, et paid by Medicare). If you don't participate, you can decide if you want to accept assignment. Since most chiropractic services will not be covered by Medicare, most chiropractors choose not to accept assignment, preferring to get paid directly by the patient for all services.
BUT, if you don't accept assignment and you bill Medicare patients for services not covered by Medicare, you must notify the patients that they must pay you directly and that they can't expect Medicare to pay. This is actually a smart thing to require, since many elderly don't know what Medicare pays and what they don't, so it's helpful to have this conversation with them in the beginning of care. You must have them sign an ABN (Advanced Beneficiary Notification) before you begin to provide services to a Medicare patient. Here is the link to this form: http://www.cms.hhs.gov/BNI/Downloads/CMSR131G.pdf
To recap:
1. Get the NPI and apply to be a Medicare provider (855I for sole
proprietor; 855B for other forms of practice). Also get an NPI for
your practice if you are not starting out as a sole proprietor.
2. Decide if you want to be a PAR provider. If you do, get the CMS-460 form and apply after you become a provider.
3. Decide if you want to accept assignment. If you don't want to accept assignment, have all Medicare patients sign an ABN.
