Medicare Resource Center

Medicare Advocacy and Assistance

The NCMS offers this central on-line location for news and information doctors need to know about Medicare, including efforts to obtain a permanent fix for the flawed Sustainable Growth Rate (SGR) formula. From the fee schedules from our local Medicare carrier to a downloadable copy of the Medicare opt-out affidavit, this is your resource center for all topics concerning Medicare and your practice.

 

Physician Payment Reform – SGR Fix

The Medicare Sustainable Growth Rate (SGR) was enacted by the Balanced Budget Act of 1997 as a method to control spending by Medicare on physician services. This flawed formula results in steep cuts to physician reimbursement as well as delays in payment as Congress has repeatedly had to enact temporary patches to the system. The North Carolina Medical Society urges Congress to enact a permanent fix to this broken system. For the latest SGR-related news, view the NCMS Blog

Our Local Medicare Carrier: Palmetto GBA

Palmetto GBA has administered Medicare health insurance for the Centers for Medicare & Medicaid Services (CMS) throughout the US and its territories since the inception of the program in 1966.

Contact Palmetto GBA:
 
Toll Free Telephone
1-800-Medicare (1-800 633-4227)
TTY: 877-486-2048
 
Address
Medicare Beneficiary Contact Center
P.O. Box 39
Lawrence, KS 66044
 
Web site
Visit Palmetto GBA’s site or go to www.medicare.gov for more information about the Medicare Program.
 
Palmetto GBA Resources

PECOS

Medicare Provider Enrollment, Chain, and Ownership System (PECOS)

PECOS supports the Medicare Provider and Supplier enrollment process by allowing registered users to securely and electronically submit and manage Medicare enrollment information.

NOTE: All physicians who refer or order for Medicare (unless opted out) are required by the Affordable Care Acto to enroll in PECOS.

Medicare Physician Participation

Physicians have three options that govern their participation status in the Medicare program for an entire calendar year:

  • Participating (PAR): Physician signs a participation agreement with Medicare agreeing to take assignment on all Medicare claims as payment in full for all covered services. PAR physicians are paid 100% of the Medicare fee schedule amount for covered services.
  • Non-Participating (Non-PAR): Physicians can either accept assignment for Medicare patients or pursue payment from patients on unassigned claims. On assigned claims, non-PAR physicians are paid 95% of the Medicare fee schedule amount for covered services. However, on unassigned claims, non-PAR physicians may collect up to 109.25% of the Medicare fee schedule amount, assuming their patient pays.
  • Private Contracting/Opting Out: This third option permits physicians to privately contract in writing with all patients to provide health care services outside the Medicare reimbursement system. People often confuse the two, but opting-out is different from being non-PAR. The amount agreed upon by the physician and patient might bear little relation to the Medicare fee schedule amounts. By law, this private contract between a physician and a patient must contain certain provisions.

Medicare Opt-Out Affidavit: J11 Part B

 
 
 
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