If you’re a doctor, health care practitioner, or other medical service provider, you may want to know how to enroll as a Medicare provider and whether it’s a good idea. Becoming a provider will allow you to directly bill Medicare for the services you offer to Medicare patients.
Not all health care providers choose to accept Medicare, but it can be especially important for you if your practice is aimed at aging or elderly patients who depend on Medicare for care. If you only accept private insurance and can’t bill Medicare for these services, you may have to turn patients away, which can be bad both for your reputation and for your bottom line.
By accepting Medicare, you can treat a larger pool of patients, and can continue seeing your current patients even after they turn 65 and enroll in Medicare. Let’s take a look at who can become a Medicare provider and what steps you’ll need to take to enroll.
Who Qualifies As a Medicare Provider?
Enrolling as a provider isn’t an easy process, so before you get started, you’ll want to make sure you’re eligible and can meet the certification requirements. You can expect it to take around 60 days to complete the enrollment process if you have all of your paperwork in order.
Who can become a provider? In general, any licensed practitioner who offers services that are covered by Medicare Parts A through D will be eligible to enroll. This includes doctors, dentists, home health care aides, dietitians, speech language pathologists, and more. It’s important that you’re licensed in your state for the services you provide.
Clinics, hospitals, laboratories, pharmacies, and other groups are also eligible to enroll, as long as you offer products or services that are covered by Medicare. These include any of the four parts of Medicare, including prescription drugs (Part D) and medical devices (Part B). If you’re unsure whether your business qualifies, you can call your state’s Medicare Administrative Contractor (MAC) to confirm your eligibility.
You’ll also need to get a National Provider Identification (NPI) number. Even if you don’t plan to enroll as a Medicare provider, you may need this number to engage with other providers, such as labs that you refer patients to for lab work. Getting an NPI number is free and you can apply online in just a few minutes. You’ll be able to use this number to identify yourself to Medicare, Medicaid, private insurers, and any other health care entity you work with.
Benefits of Medicare Provider Enrollment
Enrolling as a Medicare provider can be a big decision, especially if you have a private practice and manage your own billing. You may be worried about how accepting Medicare will affect your billing practices and your income stream, or your ability to accept or decline new patients.
First, you should know that becoming a Medicare provider doesn’t require you to accept all new patients who have Medicare. It simply means that when you do take on Medicare patients, you agree to adhere to Medicare-approved amounts and billing practices.
You can choose to be a participating provider and accept Medicare assignment, which means you’ll charge no more for services than the amount approved by Medicare. You’ll bill Medicare for 80% of the cost and the patient will pay you 20% as well as their copay and deductible.
If you don’t accept assignment, you can charge up to 15% more than the Medicare approved amount, which the patient will have to pay out of pocket. However, you’ll receive 5% less in reimbursements from Medicare than participating providers receive. You’ll also have less options to appeal a decision if a claim you submit is denied.
If you opt out of Medicare entirely, then you can’t bill Medicare for services you provide at all. This means that a patient on Medicare can still choose to see you, but they’ll have to enter a private contract with you and agree to pay for your services out of pocket.
So while becoming a Medicare provider limits the amount you can charge individual patients, you’ll be able to accept a wider pool of patients. You can bill Medicare directly for the services you offer, and your patients can continue to see you, even if they switch to Medicare from a private insurer. You won’t have to turn away patients based on their ability to pay.
Whether it makes sense to enroll as a provider depends on your field of practice and whether Medicare covers your services in the first place. For example, Medicare doesn’t cover elective cosmetic surgery, so it may not be worth enrolling as a provider unless you also offer medically necessary cosmetic surgery. But even if practitioners in your field, such as psychiatry, don’t typically accept Medicare, you can stand out by being one of the few that does.
As Medicare expands to cover mental health and preventive care services, a growing number of recipients will seek out wellness practitioners such as counselors and dietitians. If you offer any of these services, then enrolling as a Medicare provider will ensure that you can accept these patients without any hassles or delays.
How to Enroll
If you’re ready to enroll as a Medicare provider, first make sure that you’ve applied for your NPI number from the National Plan & Provider Enumeration System. It will only take a few minutes, but you’ll need this number to get any further in the process.
Next, you can apply to become an approved provider via the online PECOS portal, which is the Medicare Provider Enrollment, Chain, and Ownership System. Although you can submit a paper application if you prefer, the Center for Medicare & Medicaid Services recommends using the online form to ensure that you’ll get timely updates as your application is processed.
Some of the documents you’ll need to submit include:
- Documentation from the IRS with your business name and tax ID
- A voided check or bank statement showing your business bank account information (for EFT payments you’ll receive through the Medicare system)
- Registration with the DEA (Drug Enforcement Administration) if applicable
- Reports of adverse legal action taken against your practice
- The application fee, which is $586 as of 2019
Institutional applicants, such as clinics and laboratories, may have to provide more information than individual practitioners. In addition, health care facilities may be subject to an unannounced inspection to ensure that your location is compliant with Medicare’s standards.
Your state’s MAC (Medicare Administrative Contractor) will contact you if additional information is needed. You’ll have 30 days to respond to the request before your application is rejected.
If you’ve submitted all of the required information and your application is approved, you should hear back from the MAC within 90 days with a Provider Transaction Access Number (PTAN). You’ll have another 90 days to decide whether to enroll as a “participating provider.”
Participating providers must accept Medicare assignment and the Medicare approved amount, while non-participating providers can charge up to 15% more to patients but receive 5% less in payments from Medicare. You can only change your status during the open enrollment period each year, which typically runs from November through December.
Once you’re enrolled, you’ll be able to bill Medicare through the online system. In most states, your contract with Medicare will be valid for up to a year and can be renewed.
Maintaining Your Medicare Provider Status
Depending on the type of service or supplies you offer, your status must be revalidated every 3 to 5 years. This is separate from the contract renewal and can be completed within the PECOS system. You must also update your information any time there is a change in your status, such as relocation to a different address, change of ownership, or adverse legal action.
You can find the date that your revalidation is due using the Medicare Revalidation Lookup Tool. You’ll also receive a notice in the mail 2-3 months before from your MAC.
If you don’t revalidate in time, you may have your billing privileges suspended and be unable to receive payments. Large groups should plan ahead to coordinate their revalidation.
Enrolling as a Medicare provider may seem like a complicated process, but it can open your practice up to a larger pool of patients and can help you provide consistent care throughout a patient’s life. You’ll have access to a centralized billing platform and won’t have to turn away clients because of changes to their insurance status or financial situation.
As more and more Baby Boomers become eligible for Medicare, it’s important to make sure they have access to comprehensive health care, including mental health, wellness care, and preventive services. As a Medicare provider, you can be a part of that system and provide quality health care to patients of all ages.
If you’re unsure whether you qualify as a Medicare provider or you need help understanding the process, reach out to the team at The Medicare Store. Our team of licensed insurance agents understands the Medicare system inside and out and can help you get started! Just send a message via our contact form and one of our team members will get back to you.