When Is a Par Not a Par?

An APA member who recently called the Managed Care Help Line of APA's Office of Healthcare Systems and Financing asked how a psychiatrist enrolled in Medicare as a nonparticipating provider (a provider who does not accept assignment and whose patients pay for services and are then reimbursed by Medicare) may also have services billed as a participating provider (par).

The caller understood that a nonparticipating provider (nonpar) can participate on claims at will, but receives only 95 percent of the participating fee. However, the caller could not understand how a physician who had specifically enrolled in Medicare as either par or nonpar can be paid as par at one location and as nonpar somewhere else.

In fact, a psychiatrist who is enrolled in Medicare as a nonpar solo practitioner may be considered a participating provider when he or she does work that is billed through a clinic enrolled as a Medicare participant. Payments made through the clinic, even for care provided by a physician who in private practice is nonparticipating, are calculated according to the status of the clinic, or “billing provider.”

Any billing done through the private practice and reimbursed directly to the psychiatrist is paid the nonpar rates.

This has particular significance for filling out Form 1500 claims with your National Provider Identifier (NPI). When the “Rendering Provider” (Box 24.J on Form 1500) is the same as the “Billing Provider” (Box 33), which is the case for a psychiatrist who has not incorporated and thus is billing from his or her practice, Box 24.J is left blank.

The rendering provider's NPI is to be listed only when the billing is done through another entity, such as the physician's corporation or a clinic. In the case of a physician who is incorporated, Box 24.J requires the Type 1 NPI for the provider, and Box 33 requires the Type 2 NPI for the provider's corporation (see PP&MC in the January 18 issue).

Guidance from the Centers for Medicare and Medicaid Services on filling out Form 1500 is posted at<www.cms.hhs.gov/MLNMattersArticles/downloads/SE0729.pdf>. You can also contact APA's Managed Care HelpLine for more information by e-mailing [email protected] or calling (800) 343-4671. ▪