Medicare Frequently Asked Questions: Audiology
Enrollment & Participation
I am enrolling in Medicare. Where do I start?
Basic information about the enrollment process is available on the Centers for Medicare Services (CMS) website. You may also find this on your local Medicare contractor's website [PDF], located by state.
Audiologists who choose to see Medicare beneficiaries can become either Medicare participating or non-participating providers by using the CMS 855i [PDF] enrollment form. In order to be assigned your Medicare specific Provider Transaction Access Number (PTAN), formerly known as the Provider Identifier Number (PIN), you must file this form. You will need to have your National Provider Identifier (NPI) available when completing the form. If you don't have your NPI, you can enroll online at the National Plan and Provider Enumeration System (NPPES) website. You must have completed your terminal audiology degree and received the diploma before you can apply for an NPI. The 855i may be filed hard copy [PDF] or online.
For those providing audiologic services as an employee or as a contractor with that contractor filing the claims with the NPI of the audiologist on the CMS 1500 claim form, the CMS 855R [PDF] needs to be filed to assign the benefits to the employer or contractor.
For those providing audiologic services as part of a group, the CMS 855B [PDF] form should be filed.
If possible, audiologists should use the Provider Enrollment Chain & Ownership System (PECOS). This electronic enrollment system will also require the hard copy submission of your supporting documentation such as your degree(s), state license, and NPI notification in addition to the signed certification statement found in section 15 in order for the application to be considered complete.
As an enrolled audiologist, you must complete the Medicare Participating Physician or Supplier Agreement [PDF].
This form enters you "…into an agreement with the Medicare program to accept assignment of the Medicare Part B payment for all services for which the participant is eligible to accept assignment under the Medicare law and regulations and which are furnished while this agreement is in effect."
You can also file the CMS Electronic Transfer Fund 588 form [PDF] to allow payments to be deposited directly into your bank account. Audiologists may choose to see Medicare beneficiaries and not charge for diagnostic services.
What are the options for participation in Part B Medicare?
There are two categories of participation within Medicare: Participating provider (who must accept assignment) and non-participating provider (who does not accept assignment).
You may agree to be a participating provider with Medicare. Once enrolled, you are required to bill on an assignment basis and accept the Medicare allowable fee as payment in full. Medicare will accept 80% of the allowable amount of the Medicare Physician Fee Schedule (MPFS) and the patient will pay a 20 % co-insurance at the time services are rendered or ask you to bill their Medicare supplemental policy. Both participating and nonparticipating providers are required to file the claim to Medicare.
As a nonparticipating provider you are permitted to decide on an individual claim basis whether or not to accept assignment or bill the patient on an unassigned basis. The allowable fee for a nonparticipating provider is reduced by five percent in comparison to a participating provider. Thus, if the allowable fee is $100 for a participating provider, the allowable fee for a nonparticipating provider is $95. Medicare will pay 80% of the $95. If assignment is accepted the patient is responsible for 20% of the $95. If assignment is not accepted, the patient will pay out of pocket for the service. In this case, the most the provider is permitted to charge the patient is 115% of the allowable fee. This is known as the limiting charge. Thus, using the example of the $95 allowable fee, the most you can charge the patient is $109.25 as long as the practitioner's standard fee is at least 15% above the MPFS fee. The Medicare Learning Network website [PDF] has further information on Medicare provider status.
Your status with Medicare may be changed by informing your contractor of your contracted status for the next calendar year, but only in November of the preceding year.
What is opting out of Medicare?
Opting out of Medicare allows certain providers the ability to not participate in the Medicare program and charge Medicare patients without being subject to the Medicare Physician Fee Schedule. Audiologists are not included on the list of providers who are allowed to opt out of Medicare. Audiologists are not required to accept assignment for Medicare covered services if enrolled as a non-participating provider. If a patient requests that a claim be filed to Medicare for a covered service, the mandatory claims statute requires that the claim be filed. This will therefore require the audiologist to enroll in the Medicare program and obtain a Provider Transaction Access Number (PTAN). A non-enrolled Medicare provider could provide a service at no charge as long as no other patients were charged for the same service.