Medicare providers often face an important decision: whether to become a participating (par) provider or remain non-participating (non-par). While both are enrolled in Medicare, the financial implications and billing flexibility vary significantly. For healthcare providers, practice managers, and administrators, understanding these differences is critical to making informed decisions that impact both compliance and revenue.

What Is a Non-Participating Medicare Provider?

A non-par provider is a healthcare professional who is enrolled in Medicare and has a Provider Transaction Access Number (PTAN) but has chosen not to sign a participation agreement with Medicare.

This means:

• They can see Medicare patients.
• They must still submit claims to Medicare for covered services.
• They are reimbursed at a slightly lower rate than participating providers.

Enrollment and Claim Filing Requirements

Even as non-par providers:

• Medicare requires that claims still be submitted for all covered services.
• Depending on assignment, payment can go directly to the provider or to the patient, who then reimburses the provider.

Non-par is not the same as “opt-out.” Opt-out providers cannot bill Medicare at all (except in emergencies) and must establish private contracts with patients.

Reimbursement for Non-Par Providers

• Non-par providers are reimbursed at 95% of the Medicare Physician Fee Schedule (MPFS).
• They may decide case-by-case whether to accept assignment on a claim.

Balance Billing and the Limiting Charge

Non-par providers may charge patients more than Medicare’s approved amount, up to the limiting charge.

• Limiting Charge = Medicare-approved amount + up to 15%
• Example:
  • Medicare-approved amount = $100
  • Medicare pays $95 (95% of MPFS)
  • Provider may bill the patient up to $115 total (Medicare + patient combined)

This flexibility comes with added administrative responsibilities, since providers must ensure compliance with the limiting charge rules.

Key Difference: Non-Par vs. Opt-Out Providers

It’s important to distinguish:

• Non-Par Providers: Still in Medicare, reimbursed at 95%, can balance bill up to the limiting charge, and must file claims.
• Opt-Out Providers: File an affidavit with CMS, do not accept Medicare reimbursement, and bill patients privately under a contract.

Medicare Provider Status Comparison

Why This Matters for Providers

Choosing non-par status may appeal to providers who want greater flexibility in patient billing. However, it comes with trade-offs:

• Lower reimbursement rates compared to par providers
• More administrative oversight for balance billing
• Higher potential for patient confusion over financial responsibility

How TriumpHealth Helps

At TriumpHealth, we guide providers through:

• Medicare enrollment and PTAN setup
• Understanding participation vs. non-par vs. opt-out status
• Compliance with limiting charge rules
• Revenue cycle impact analysis to determine the best fit for your practice

Conclusion

A non-participating Medicare provider is not “out of Medicare” but operates with reduced reimbursement and more flexibility in billing. Understanding the differences between participating, non-participating, and opt-out status is essential for aligning your practice’s financial goals with compliance requirements.

Need Expert Guidance?

Schedule A Consultation with TriumpHealth team to ensure your Medicare participation status supports both compliance and long-term revenue success. You can also contact us via email [email protected] or phone (888) 747-3838 x0.