*This is an archive page. The links are no longer being updated. 1992.03.25 : Medicare Participating Physicians Contact: Bob Hardy (202) 245-6145 March 25, 1992 HHS Secretary Louis W. Sullivan, M.D., announced today that 1992 is the first year in which a majority of physicians who serve Medicare patients have enrolled as "participating physicians." Secretary Sullivan described the Participating Physician program as "an important Medicare activity for consumers. By choosing a participating physician, a beneficiary will not be burdened with charges in excess of Medicare-approved amounts." A participating physician is one who has agreed to accept Medicare fee schedule amounts as full payment for services. The participation rate in 1992 has reached a record 52.2 percent, up from 47.6 percent in 1991. Participation increased in 46 states. Services provided by participating physicians account for 73 percent of Medicare-covered charges for physician services. The participation rate has increased every year since the Medicare Participating Physician program started in 1984. The data for participating physicians also includes limited license practitioners such as optometrists, podiatrists and chiropractors. Medicare pays 80 percent of the fee schedule amount for a physician's service. For a Medicare-covered service provided by a participating physician, the beneficiary is responsible for 20 percent of the fee schedule amount, while the nonparticipating physician may charge more up to a limit defined by law. - More - - 2 - If the participating physician provides a service for which the fee schedule amount is $100, Medicare pays $80 and the beneficiary is responsible for $20. However, the beneficiary could be responsible for as much as $38 for the same service by a nonparticipating physician. The Medicare charge limit set by law for 1992 is 20 percent above the fee schedule amount for a nonparticipating physician, which is five percent less than the amount for a participating physician. For a particular service, the fee schedule amount of $100 for a participating physician would be $95 for a nonparticipating physician. Medicare would pay $76, or 80 percent, leaving the beneficiary with a balance of $19 to cover the remaining 20 percent. Since the nonparticipating physician can legally charge 20 percent more than the fee schedule amount, another $19 could be added to the bill, bringing the out-of-pocket cost to the beneficiary to $38. Medicare provides the following incentives to encourage participation by physicians: o The fee schedule amounts for participating physicians are five percent higher than those for nonparticipating physicians. o Claims not requiring development are paid within 17 days for participating physicians and 24 days for nonparticipating physicians. o Medicare carriers publish directories of participating physicians for free distribution. The directories are distributed to local Social Security offices and senior citizen organizations. Carriers also operate toll-free telephone service through which beneficiaries and interested organizations can order directories. Suppliers such as ambulance services and durable medical equipment suppliers also enter participation agreements with Medicare. The participation rate of suppliers is 23.7 percent in 1992, an increase of 1.1 percentage points from 1991. ### MEDICARE PARTICIPATING PHYSICIAN AND SUPPLIER PROGRAM Participation Status January 1, 1992 January 1, 1991 Physicians* Participating 52.2% = 407,495 47.6 % = 360,765 Billing Medicare 780,131 758,363 Suppliers Participating 23.7% = 29,791 22.6% = 28,667 Billing Medicare 125,870 126,982 Total Participating 48.3% = 437,286 44.0% = 389,432 Billing Medicare 906,001 885,345 Comparison with Previous Enrollment January 1992 January 1991 Number % % Physicians* 407,495 52.2 47.6 Suppliers 29,791 23.7 22.6 Total 437,286 48.3 44.0 * Includes M.D.s, D.O.s and limited license practitioners Participation counts reflect physicians who are participating in at least one practice setting. For example, a physician who is participating in his private practice but not in his group is counted as participating.