Becoming a non-participating (“non-par”) Medicare provider is not the same as opting out of Medicare. Non-par providers still see Medicare patients, still face audits, and still follow Medicare’s rules — they simply choose, claim by claim, whether to accept assignment. If you assumed non-par meant escaping Medicare’s requirements, read on before you make a decision that surprises you later.
Non-par providers still see Medicare patients
Participating in Medicare means you agree to accept assignment for all services to Medicare patients — accepting Medicare’s approved amount as payment in full. A non-par provider can accept assignment or not on each claim. But if you do not accept assignment, you cannot charge more than 115% of the Physician Fee Schedule amount for a given service (the “limiting charge”).
That distinction trips up a lot of providers, and it feeds three common misconceptions.
Myth 1: You’ll never be audited
Any Medicare claim can be audited or reviewed, and your participation status does not change that. As CMS has stated, reviews are meant to protect the Medicare trust funds and to catch billing errors so they can be corrected. Translation: if you expect payment from Medicare, Medicaid, TRICARE, or any other government source, expect the same scrutiny regardless of your filing status. Bill and code accurately every time.
Myth 2: You can avoid EHR and quality penalties
Many non-par providers assumed that quality-reporting and EHR-related payment adjustments did not apply to them — then saw negative adjustments in their reimbursement anyway. CMS has been clear that these adjustments apply to eligible professionals regardless of participation status. Translation: if you see Medicare patients, you follow Medicare’s reporting and technology rules, or you take the pay reduction.
Myth 3: Your money will roll in as usual
If you are non-par and do not accept assignment on a claim, Medicare sends payment to the beneficiary, not to you. You calculate what Medicare allows for the service under your non-par status and collect from the patient — often at the time of service. If you wait for the patient to forward a check after their MAC pays them, set a reminder to bill and follow up, or you risk not collecting at all.
The bottom line
Non-par status gives you flexibility, but it does not release you from Medicare compliance, audits, or quality rules — and it changes how and from whom you collect. Understand those trade-offs before you choose, and make sure your enrollment records reflect the status you intend.
Provider Enrollment Services handles Medicare provider enrollment and PECOS work in-house, so your participation status, revalidations, and reassignments are set up correctly. Explore our Medicare provider enrollment services, check your Medicare revalidation due date, or request a quote at (800) 406-4796.
Enrollment status, coverage, and reimbursement rules are set by CMS and its Medicare carriers, not by PES.