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How Does Medicare Approve Medicare Providers?

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Summary: Medicare providers are health-care providers that are approved by Medicare. In order to be approved, Medicare providers have to enroll in the Medicare program and pass a state inspection.

If you’re on Medicare, you might wonder how Medicare providers are chosen. Can any doctor or other provider be a Medicare provider? Learn how Medicare approves doctors, nurses, hospitals, and other providers.

Who are Medicare providers?

Medicare providers are health-care providers who have been approved or “certified” by Medicare.  A provider’s enrollment with Medicare often affects whether Medicare will cover his services. Typically, Medicare must approve providers before they’re paid for covered services.

What types of approved Medicare providers are there?

Institutional providers – According to the Centers for Medicare & Medicaid Services (CMS), institutional Medicare providers are – well – institutions. These can be hospitals, rehabilitation facilities, skilled nursing facilities, surgical centers, home health agencies, dialysis centers, and other types of health-care facilities.

Institutional Medicare providers generally have to pass a state inspection. The inspection may look at things like the facility’s:

  • Licensing – does the Medicare provider have all appropriate licenses?
  • Medical record system – are records handled and stored properly?
  • Practice environment – is it safe for patients? Does it meet quality standards?

CMS typically approves the facility as a Medicare provider based on the state agency’s positive recommendation and supporting evidence. This inspection is repeated every few years to assure the Medicare provider continues to meet Medicare’s requirements.

Other practitioners and medical suppliers – Some Medicare providers fall within the category of “physicians and non-physician practitioners.” These include a wide range of providers, like:

  • Cardiac surgeons
  • Oncologists
  • Pain management specialists
  • Emergency medical providers
  • Neurologists
  • Internal medicine providers
  • Podiatrists
  • Clinical social workers
  • Nurse practitioners

…and many more. There may be other types of Medicare providers as well, such as durable medical equipment providers.

To be Medicare-certified, providers typically have to enroll in the Medicare program. Providers have to prove they have the appropriate licenses and other certification. They also have to list any “adverse legal actions” – for example, has the doctor’s license ever been suspended? Medicare considers all this information as part of the Medicare provider approval process.

Why is it important to know if your doctor is a Medicare provider?

Medicare providers have agreements with Medicare that may benefit you. For example, Medicare providers agree to accept the Medicare-approved amount as their full payment for covered services. This is sometimes called “accepting Medicare assignment.”

A doctor who accepts assignment generally can’t charge more than the Medicare-approved amount for covered services. Medicare providers also agree to file medical claims for their services. Usually you won’t have to mail in a medical claim. Generally, you will only have to pay your cost-share (deductible, copayment, or coinsurance) amount. That’s true whether you have Original Medicare (Part A and Part B) or other Medicare coverage, like a Medicare Advantage plan.

What about Medicare providers and others who don’t accept Medicare payment terms?

When it comes to covering your medical services, Medicare looks at agreements that providers have (or don’t have) with Medicare.

  • Participating Medicare providers always accept Medicare assignment for covered services and file claims for services
  • Non-participating Medicare providers accept Medicare but don’t agree to take assignment in every case. They might not accept Medicare’s approved amount for health care services as full payment. You may be charged up to 15% more than the Medicare-approved amount for services in some cases.
  • Opt-out providers do not accept Medicare at all and have signed an agreement to be excluded from the Medicare program. This means they can charge whatever they want for services.

If you have a Medicare Advantage plan that has a provider network, you can generally expect network providers to be Medicare-approved. Otherwise, you might want to make sure your doctor is a Medicare provider before your office or hospital visit. You can ask the provider’s office.

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