Physicians have until December 31, 2024, to update their Medicare participation status for 2025, with any changes going into effect on January 1, 2025. This deadline is crucial for those reevaluating their participation due to the looming payment cuts reflected in the 2025 physician fee schedule announced by the Centers for Medicare and Medicaid Services.

Unless Congress intervenes, the 2025 physician fee schedule will cut Medicare physician payments by 2.8%. However, there is hope that Congress will act to prevent this cut by the end of the year. A bipartisan group of U.S. Representatives have introduced the Medicare Patient Access and Practice Stabilization Act of 2024 (HR 10073) to stabilize physician practices and improve patient access to care. The bill would stop the impending 2.8% Medicare physician payment cut in 2025 and provide a partial inflation update – 50% of the Medicare Economic Index for one year in 2025 – to help address inflationary increases in medical practice costs. Under HR 10073, the total Medicare physician payment increase for 2025 would be 4.73%.  

Medicare Participation Options

As always, physicians have three choices regarding Medicare: Be a participating provider; be a non-participating provider; or opt out of Medicare entirely. Details on each of the three participations options are as follows:

A participating physician must accept Medicare-allowed charges as payment in full for all Medicare patients. A participating provider receives 5% more reimbursement than a non-participating provider.

A non-participating provider can make assignment decisions on a case-by-case basis and bill patients for more than the Medicare allowance for unassigned claims. Non-participating physician fees are 95% of participating physician fees. If you choose not to accept assignment, you can charge the patient 9.25% more than the amounts allowed in the participating physician fee schedule (which equates to 15% of the non-participating fees).

Physicians who opt out of Medicare are bound only by their private contracts with their patients. Medicare's limiting charges do not apply to these contracts, but Medicare does specify that these contracts contain certain terms. When a physician enters into a private contract with a Medicare beneficiary, both the physician and patient agree not to bill Medicare for services provided under the contract. Validated opt-out affidavits automatically renew two years after the effective date.

Physicians who want to change their participation status for 2025 must submit a signed Medicare Participating Physician or Supplier Agreement (CMS-460) to Noridian, California’s Medicare contractor, postmarked by December 31, 2024. While participation agreements will automatically renew each year, you will need to complete a new participation agreement if there is a name or EIN (tax identification number) change.

There is also information on physicians' Medicare participation options in California Medical Association (CMA) health law library document #7209, "Medicare Participation (and Nonparticipation) Options." Health law library documents are free to CMA members at cmadocs.org/health-law-library. Nonmembers can purchase documents for $3 per page.

For More Information

Noridian is hosting a Provider Enrollment Basics and Overview webinar that will provide information about provider enrollment and how the process works. The free webinar will be Wednesday, December 11, at 11 am Pacific Time. Click here to register.

More information on open enrollment is also available on the Noridian website.

Questions? Contact CMA’s Medicare specialist Cheryl Bradley at (916) 551-2862 or cbradley@cmadocs.org.