Physician Status Options Regarding Medicare

PAR:

The Participating or PAR physician is, today, the most common, but also the fastest shrinking group. PAR physicians bill and collect directly from Medicare. PAR physicians are subject to all the compliance rules, regulations, as well as reporting requirements established by the government. There were, before ObamaCare, more than 130,000 pages of regulations concerning how a physician should run their office. Violation of any of these regulations can result in fines of more than $10,000 for each occurrence. Most PAR physicians have had to hire additional personnel or outside services to document compliance, avoid fines, and potentially gain some small incentives from the government.

NON-PAR:

These doctors are allowed to charge a small amount more than the Medicare allowable. However, they collect from the patient, and the patient collects from Medicare. NON-PAR physicians are also limited in their fees. NON-PAR physicians are subject to all of the same rules and regulations as PAR physicians.

Opted Out:

Opted out physicians are freed from almost all Medicare requirements. Neither the physician nor the patient can bill Medicare. The financial relationship remains between the patient and the physician and is a fee for service basis. The fee is set between the two and is not regulated by the government. While the PAR and NON-PAR physician must have documentation that they made every effort to collect all co-pay amounts, the Opted Out physician may, at his or her own discretion, provide discounts or free service to their patients.

All ancillary services ordered by the opted out physician at facilities that accept Medicare are paid in their normal manner by Medicare.

The only rules and regulations to which an Opted Out physician is subject are those required to protect the ancillary services required by patients. Two quick examples, one is reasonable, the other not so. For the hospital to be paid by Medicare, the hospital must document and report compliance with many rules relative to the hospital stay. Perioperative antibiotics (antibiotics given during the course of the operation) is one such reasonable regulation. On the other hand, there are requirements for the documentation of failure of non-operative treatment prior to elective surgery that increase the overall cost of treatment and potentially limit outcomes. Many of these requirements also apply to all patients of Medicare age whether Medicare is their primary insurance or it is not.

Dis-Enrolled:

Dis-Enrolled physicians have no relationship with Medicare. The patient of the Dis-Enrolled physician pays fee for service not only for the care by the physician, but also for any and all ancillary services ordered by the Dis-Enrolled physician.