7Types of Medicare Reimbursement
Participating Provider
Most providers in Medicare belong to this category. They are signed contractors that accept assignment from Medicare and CMS set rates for services. Participating providers will bill directly. Therefore, you do not need to file a reimbursement claim. In some rare circumstances, these providers would refuse or fail to file a claim, so you need to pay for these services directly. But they are responsible for doing this task when they accept assignment. [7]
Non-participating Provider
Non-participating providers do not accept assignment from Medicare. While they would accept patients from Medicare, they have not reached an agreement on Medicare rate for all services. Therefore, you would need to pay for a service up to 15 percent higher than the Medicare-set rate. Depending on the state, this limit can be set to 5 percent. Overall, certain non-participating providers may bill Medicare directly, while others would ask you to pay for their services directly and then file a reimbursement claim on your own. [8]
