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Medicare Assignment
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Summary: If a provider accepts Medicare assignment, they accept the Medicare-approved amount for a covered service. Though most providers accept assignment, not all do. In this article, we’ll explain the differences between participating, non-participating, and opt-out providers. You’ll also learn how to find physicians in your area who accept Medicare assignment. Estimated Read Time: 5 min
What is Medicare Assignment
Medicare assignment is an agreement by your doctor or other healthcare providers to accept the Medicare-approved amount as the full cost for a covered service. Providers who “accept assignment” bill Medicare directly for Part B-covered services and cannot charge you more than the applicable deductible and coinsurance.
Most healthcare providers who opt-in to Medicare accept assignment. In fact, CMS reported in its Medicare Participation for Calendar Year 2024 announcement that 98 percent of Medicare providers accepted assignment in 2023.
Providers who accept Medicare are divided into two groups: Participating providers and non-participating providers. Providers can decide annually whether they want to participate in Medicare assignment, or if they want to be non-participating.
Providers who do not accept Medicare Assignment can charge up to 15% above the Medicare-approved cost for a service. If this is the case, you will be responsible for the entire amount (up to 15%) above what Medicare covers.
Below, we’ll take a closer look at participating, non-participating, and opt-out physicians.
Medicare Participating Providers: Providers Who Accept Medicare Assignment
Healthcare providers who accept Medicare assignment are known as “participating providers”. To participate in Medicare assignment, a provider must enter an agreement with Medicare called the Participating Physician or Supplier Agreement. When a provider signs this agreement, they agree to accept the Medicare-approved charge as the full charge of the service. They cannot charge the beneficiary more than the applicable deductible and coinsurance for covered services.
Each year, providers can decide whether they want to be a participating or non-participating provider. Participating in Medicare assignment is not only beneficial to patients, but to providers as well. Participating providers get paid by Medicare directly, and when a participating provider bills Medicare, Medicare will automatically forward the claim information to Medicare Supplement insurers. This makes the billing process much easier on the provider’s end.
Medicare Non-Participating Providers: Providers Who Don’t Accept Assignment
Healthcare providers who are “non-participating” providers do not agree to accept assignment and can charge up to 15% over the Medicare-approved amount for a service. Non-participating Medicare providers still accept Medicare patients. However they have not agreed to accept the Medicare-approved cost as the full cost for their service.
Doctors who do not sign an assignment agreement with Medicare can still choose to accept assignment on a case-by-case basis. When non-participating providers do add on excess charges , they cannot charge more than 15% over the Medicare-approved amount. It’s worth noting that providers do not have to charge the maximum 15%; they may only charge 5% or 10% over the Medicare-approved amount.
When you receive a Medicare-covered service at a non-participating provider, you may need to pay the full amount at the time of your service; a claim will need to be submitted to Medicare for you to be reimbursed. Prior to receiving care, your provider should give you an Advanced Beneficiary Notice (ABN) to read and sign. This notice will detail the services you are receiving and their costs.
Non-participating providers should include a CMS-approved unassigned claim statement in the additional information section of your Advanced Beneficiary Notice. This statement will read:
“This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”
This statement basically summarizes how excess charges work: Medicare will pay the Medicare-approved amount, but you may end up paying more than that.
Your provider should submit a claim to Medicare for any covered services, however, if they refuse to submit a claim, you can do so yourself by using CMS form 1490S .
Opt-Out Providers: What You Need to Know
Opt-out providers are different than non-participating providers because they completely opt out of Medicare. What does this mean for you? If you receive supplies or services from a provider who opted out of Medicare, Medicare will not pay for any of it (except for emergencies).
Physicians who opt-out of Medicare are even harder to find than non-participating providers. According to a report by KFF.org, only 1.1% of physicians opted out of Medicare in 2023. Of those who opted out, most are physicians in specialty fields such as psychiatry, plastic and reconstructive surgery, and neurology.
How to Find A Doctor Who Accepts Medicare Assignment
Finding a doctor who accepts Medicare patients and accepts Medicare assignment is generally easier than finding a provider who doesn’t accept assignment. As we mentioned above, of all the providers who accept Medicare patients, 98 percent accept assignment.
The easiest way to find a doctor or healthcare provider who accepts Medicare assignment is by visiting Medicare.gov and using their Compare Care Near You tool . When you search for providers in your area, the Care Compare tool will let you know whether a provider is a participating or non-participating provider.
If a provider is part of a group practice that involves multiple providers, then all providers in that group must have the same participation status. As an example, we have three doctors, Dr. Smith, Dr. Jones, and Dr. Shoemaker, who are all part of a group practice called “Health Care LLC”. The group decides to accept Medicare assignment and become a participating provider. Dr. Smith decides he does not want to accept assignment, however, because he is part of the “Health Care LLC” group, he must remain a participating provider.
Using Medicare’s Care Compare tool, you can select a group practice and see their participation status. You can then view all providers who are part of that group. This makes finding doctors who accept assignment even easier.
To ensure you don’t end up paying more out-of-pocket costs than you anticipated, it’s always a good idea to check with your provider if they are a participating Medicare provider. If you have questions regarding Medicare assignment or are having trouble determining whether a provider is a participating provider, you can contact Medicare directly at 1-800-633-4227. If you have questions about excess charges or other Medicare costs and would like to speak with a licensed insurance agent, you can contact us at the number above.
Announcement About Medicare Participation for Calendar Year 2024, Centers for Medicare & Medicaid Services. Accessed January 2024
https://www.cms.gov/files/document/medicare-participation-announcement.pdf
Annual Medicare Participation Announcement, CMS.gov. Accessed January 2024
https://www.cms.gov/medicare-participation
Does Your Provider Accept Medicare as Full Payment? Medicare.gov. Accessed January 2024
https://www.medicare.gov/basics/costs/medicare-costs/provider-accept-Medicare
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What is Medicare assignment and how does it work?
Kimberly Lankford,
Because Medicare decides how much to pay providers for covered services, if the provider agrees to the Medicare-approved amount, even if it is less than they usually charge, they’re accepting assignment.
A doctor who accepts assignment agrees to charge you no more than the amount Medicare has approved for that service. By comparison, a doctor who participates in Medicare but doesn’t accept assignment can potentially charge you up to 15 percent more than the Medicare-approved amount.
That’s why it’s important to ask if a provider accepts assignment before you receive care, even if they accept Medicare patients. If a doctor doesn’t accept assignment, you will pay more for that physician’s services compared with one who does.
How much do I pay if my doctor accepts assignment?
If your doctor accepts assignment, you will usually pay 20 percent of the Medicare-approved amount for the service, called coinsurance, after you’ve paid the annual deductible. Because Medicare Part B covers doctor and outpatient services, your $240 deductible for Part B in 2024 applies before most coverage begins.
All providers who accept assignment must submit claims directly to Medicare, which pays 80 percent of the approved cost for the service and will bill you the remaining 20 percent. You can get some preventive services and screenings, such as mammograms and colonoscopies , without paying a deductible or coinsurance if the provider accepts assignment.
What if my doctor doesn’t accept assignment?
A doctor who takes Medicare but doesn’t accept assignment can still treat Medicare patients but won’t always accept the Medicare-approved amount as payment in full.
This means they can charge you up to a maximum of 15 percent more than Medicare pays for the service you receive, called “balance billing.” In this case, you’re responsible for the additional charge, plus the regular 20 percent coinsurance, as your share of the cost.
How to cover the extra cost? If you have a Medicare supplement policy , better known as Medigap, it may cover the extra 15 percent, called Medicare Part B excess charges.
All Medigap policies cover Part B’s 20 percent coinsurance in full or in part. The F and G policies cover the 15 percent excess charges from doctors who don’t accept assignment, but Plan F is no longer available to new enrollees, only those eligible for Medicare before Jan. 1, 2020, even if they haven’t enrolled in Medicare yet. However, anyone who is enrolled in original Medicare can apply for Plan G.
Remember that Medigap policies only cover excess charges for doctors who accept Medicare but don’t accept assignment, and they won’t cover costs for doctors who opt out of Medicare entirely.
Good to know. A few states limit the amount of excess fees a doctor can charge Medicare patients. For example, Massachusetts and Ohio prohibit balance billing, requiring doctors who accept Medicare to take the Medicare-approved amount. New York limits excess charges to 5 percent over the Medicare-approved amount for most services, rather than 15 percent.
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How do I find doctors who accept assignment?
Before you start working with a new doctor, ask whether he or she accepts assignment. About 98 percent of providers billing Medicare are participating providers, which means they accept assignment on all Medicare claims, according to KFF.
You can get help finding doctors and other providers in your area who accept assignment by zip code using Medicare’s Physician Compare tool .
Those who accept assignment have this note under the name: “Charges the Medicare-approved amount (so you pay less out of pocket).” However, not all doctors who accept assignment are accepting new Medicare patients.
What does it mean if a doctor opts out of Medicare?
Doctors who opt out of Medicare can’t bill Medicare for services you receive. They also aren’t bound by Medicare’s limitations on charges.
In this case, you enter into a private contract with the provider and agree to pay the full bill. Be aware that neither Medicare nor your Medigap plan will reimburse you for these charges.
In 2023, only 1 percent of physicians who aren’t pediatricians opted out of the Medicare program, according to KFF. The percentage is larger for some specialties — 7.7 percent of psychiatrists and 4.2 percent of plastic and reconstructive surgeons have opted out of Medicare.
Keep in mind
These rules apply to original Medicare. Other factors determine costs if you choose to get coverage through a private Medicare Advantage plan . Most Medicare Advantage plans have provider networks, and they may charge more or not cover services from out-of-network providers.
Before choosing a Medicare Advantage plan, find out whether your chosen doctor or provider is covered and identify how much you’ll pay. You can use the Medicare Plan Finder to compare the Medicare Advantage plans and their out-of-pocket costs in your area.
Return to Medicare Q&A main page
Kimberly Lankford is a contributing writer who covers Medicare and personal finance. She wrote about insurance, Medicare, retirement and taxes for more than 20 years at Kiplinger’s Personal Finance and has written for The Washington Post and Boston Globe . She received the personal finance Best in Business award from the Society of American Business Editors and Writers and the New York State Society of CPAs’ excellence in financial journalism award for her guide to Medicare.
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If you have Original Medicare , your Part B costs once you have met your deductible can vary depending on the type of provider you see. For cost purposes, there are three types of provider, meaning three different relationships a provider can have with Medicare . A provider’s type determines how much you will pay for Part B -covered services.
- These providers are required to submit a bill (file a claim ) to Medicare for care you receive. Medicare will process the bill and pay your provider directly for your care. If your provider does not file a claim for your care, there are troubleshooting steps to help resolve the problem .
- If you see a participating provider , you are responsible for paying a 20% coinsurance for Medicare-covered services.
- Certain providers, such as clinical social workers and physician assistants, must always take assignment if they accept Medicare.
- Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of services you receive (known as the limiting charge ). This means you are responsible for up to 35% (20% coinsurance + 15% limiting charge) of Medicare’s approved amount for covered services.
- Some states may restrict the limiting charge when you see non-participating providers. For example, New York State’s limiting charge is set at 5%, instead of 15%, for most services. For more information, contact your State Health Insurance Assistance Program (SHIP) .
- If you pay the full cost of your care up front, your provider should still submit a bill to Medicare. Afterward, you should receive from Medicare a Medicare Summary Notice (MSN) and reimbursement for 80% of the Medicare-approved amount .
- The limiting charge rules do not apply to durable medical equipment (DME) suppliers . Be sure to learn about the different rules that apply when receiving services from a DME supplier .
- Medicare will not pay for care you receive from an opt-out provider (except in emergencies). You are responsible for the entire cost of your care.
- The provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not reimburse you.
- Opt-out providers do not bill Medicare for services you receive.
- Many psychiatrists opt out of Medicare.
Providers who take assignment should submit a bill to a Medicare Administrative Contractor (MAC) within one calendar year of the date you received care. If your provider misses the filing deadline, they cannot bill Medicare for the care they provided to you. However, they can still charge you a 20% coinsurance and any applicable deductible amount.
Be sure to ask your provider if they are participating, non-participating, or opt-out. You can also check by using Medicare’s Physician Compare tool .
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What You Need to Know About Medicare Assignment
If you are one of the more than 63 million Americans enrolled in Medicare and are on the lookout for a new provider, you may wonder what your options are. A good place to start? Weighing the pros and cons of choosing an Original Medicare plan versus a Medicare Advantage plan—both of which have their upsides.
Let’s say you decide on an Original Medicare plan, which many U.S. doctors accept. In your research, however, you come across the term “Medicare assignment.” Cue the head-scratching. What exactly does that mean, and how might it affect your coverage costs?
What is Medicare Assignment?
It turns out that Medicare assignment is a concept you need to understand before seeing a new doctor. First things first: Ask your doctor if they “accept assignment”—that exact phrasing—which means they have agreed to accept a Medicare-approved amount as full payment for any Medicare-covered service provided to you. If your doctor accepts assignment, that means they’ll send your whole medical bill to Medicare, and then Medicare pays 80% of the cost, while you are responsible for the remaining 20%.
A doctor who doesn’t accept assignment, however, could charge up to 15% more than the Medicare-approved amount for their services, depending on what state you live in, shouldering you with not only that additional cost but also your 20% share of the original cost. Additionally, the doctor is supposed to submit your claim to Medicare, but you may have to pay them on the day of service and then file a reimbursement claim from Medicare after the fact.
Worried that your doctor will not accept assignment? Luckily, 98% of U.S. physicians who accept Medicare patients also accept Medicare assignment, according to the U.S. Centers for Medicare & Medicaid Services (CMS). They are known as assignment providers, participating providers, or Medicare-enrolled providers.
It can be confusing. Here’s how to assess whether your provider accepts Medicare assignment, and what that means for your out-of-pocket costs:
The 3 Types of Original Medicare Providers
1. participating providers, or those who accept medicare assignment.
These providers have an agreement with Medicare to accept the Medicare-approved amount as full payment for their services. You don’t have to pay anything other than a copay or coinsurance (depending on your plan) at the time of your visit. Typically, Medicare pays 80% of the cost, while you are responsible for the remaining 20%, as long as you have met your deductible.
2. Non-participating providers
“Most providers accept Medicare, but a small percentage of doctors are known as non-participating providers,” explains Caitlin Donovan, senior director of public relations at the National Patient Advocate Foundation (NPAF) in Washington D.C. “These may be more expensive,” she adds. Also known as non-par providers, these physicians may accept Medicare patients and insurance, but they have not agreed to take assignment Medicare in all cases. That means they’re not held to the Medicare-approved amount as payment in full. As a reminder, a doctor who doesn’t accept assignment can charge up to 15% more than the Medicare-approved amount, depending on what part of the country you live in, and you will have to pay that additional amount plus your 20% share of the original cost.
What does that mean for you? Besides being charged more than the Medicare-approved amount, you might also be required to do some legwork to get reimbursed by Medicare.
- You may have to pay the entire bill at the time of service and wait to be reimbursed 80% of the Medicare-approved amount. In most cases, the provider will submit the claim for you. But sometimes, you’ll have to submit it yourself.
- Depending on the state you live in, the provider may also charge you as much as 15% more than the Medicare-approved amount. (In New York state, for example, that add-on charge is limited to 5%.) This is called a limiting charge—and the difference, called the balance bill, is your responsibility.
There are some non-par providers, however, who accept Medicare assignment for certain services, on a case-by-case basis. Those may include any of the services—anything from hospital and hospice care to lab tests and surgery—available from any assignment-accepting doctor, with a key exception: If a non-par provider accepts assignment for a particular service, they cannot bill you more than the regular Medicare deductible and coinsurance amount for that specific treatment. Just as it’s important to confirm whether your doctor accepts assignment, it’s also important to confirm which services are included at assignment.
3. Opt-out providers
A small percentage of providers do not participate in Medicare at all. In 2020, for example, only 1% of all non-pediatric physicians nationwide opted out, and of that group, 42% were psychiatrists. “Some doctors opt out of providing Medicare coverage altogether,” notes Donovan.“In that case, the patient would pay privately.” If you were interested in seeing a physician who had opted out of Medicare, you would have to enter a private contract with that provider, and neither you nor the provider would be eligible for reimbursement from Medicare.
How do I know if my doctor accepts Medicare assignment?
The best way to find out whether your provider accepts Medicare assignment is simply to ask. First, confirm whether they are participating or non-participating—and if they are non-participating, ask whether they accept Medicare assignment for certain services.
Also, make sure to ask your provider exactly how they will be billing Medicare and what charges you might expect at the time of your visit so that you’re on the same page from the start.
Is seeing a non-participating provider who accepts Medicare assignment more expensive?
The short answer is yes. There are usually out-of-pocket costs after you’re reimbursed. But it may not cost as much as you think, and it may not be much more than if you see a participating provider. Still, it could be challenging if you’re on a fixed income.
For example, let’s say you’re seeing a physical therapist who accepts Medicare patients but not Medicare assignment. Medicare will pay $95 per visit to the provider; but your provider bills the service at $115. In most states, you’re responsible for a 15% limiting charge above $95. In this case, your bill would be 115% of $95, or $109.25.
Once you get your $95 reimbursement back from Medicare, your cost for the visit—the balance bill—would be $14.25 (plus any deductibles or copays) .
In some states, the maximum cap on the limiting charge is less than 15%. As mentioned earlier, New York state, for instance, allows only a 5% surcharge, which means that physical therapy appointment would cost you just $4.75 extra.
Bottom line: Medicare assignment providers and non-participating providers who agree to accept Medicare assignment are both viable options for patients. So if you want to see a particular provider, don’t rule them out just because they’re non-par.
While seeing a non-participating provider may still be affordable, ultimately, the biggest headache may be keeping track of claims and reimbursements, or simply setting aside the right amount of money to pay for your visit up front.
Before you schedule a visit, be sure to ask how much the service will cost. You can also estimate the payment amount based on Medicare-approved charges. A good place to start is this out-of-pocket expense calculator provided by the CMS.
What if I see a provider who opts out of Medicare altogether?
An opt-out provider will create a private contract with you, underscoring the terms of your agreement. But Medicare will not reimburse either of you for services.
Seeing a provider who does not accept Medicare will likely be more expensive. And your visits won’t count toward your deductible. But you may be able to work out paying reduced fees on a sliding scale for that provider’s services, all of which would be laid out in your contract.
Assignment of Benefits
An agreement by a doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill the beneficiary for any more than the Medicare deductible and coinsurance.
- Assignment is a term used to describe the agreement between a healthcare provider and Medicare to accept the Assignment is a term used to describe the agreement between a healthcare provider and Medicare to accept the.
- If a beneficiary is enrolled in Medicare , and they visit a provider who accepts assignment, they may be responsible for paying a copayment or coinsurance for certain services. These out-of-pocket costs are typically a small percentage of the overall cost of the service and are required to be paid at the time the service is provided.
- It is important to note that not all providers accept assignments. Some providers may choose to bill Medicare directly for the services they provide but may also bill the beneficiary for any amount not covered by Medicare. This is known as nonassigned billing, and it is important to be aware the beneficiary may be responsible for paying a larger out-of-pocket cost if they visit a provider who does not accept assignment.
- If a beneficiary is considering receiving medical care from a provider who does not accept assignment,it is recommended they discuss the costs of the services with the provider and confirm whether they will be responsible for paying any additional out-of-pocket costs.
Understanding AOB is essential for Medicare beneficiaries to ensure they are not billed for healthcare services covered by Medicare beyond their financial responsibility. AOB helps simplify the billing process for beneficiaries and ensures they are not subject to unexpected out-of-pocket expenses for covered services.
Interested in learning more about how Assignment of Benefits works and its impact on Medicare coverage? Download our comprehensive E-book for valuable insights and guidance on navigating Medicare billing and coverage effectively.
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- How Medicare Assignment Works
- Accepting Assignment
- Refusing Assignment
What Is Medicare Assignment?
Key Takeaways
- Medicare assignment describes the fee structure that your doctor and Medicare have agreed to use.
- If your doctor agrees to accept Medicare assignment, they agree to be paid whatever amount Medicare has approved for a service.
- You may still see doctors who don’t accept Medicare assignment, but you may have to pay for your visit up front and submit a claim to Medicare for reimbursement.
- You may have to pay more to see doctors who don’t accept Medicare assignment.
How Does Medicare Assignment Work?
What is Medicare assignment ? Medicare assignment simply means that your provider has agreed to stick to a Medicare fee schedule when it comes to what they charge for tests and services. Medicare regularly updates fee schedules, setting specific limits for what it will cover for things like office visits and lab testing. When a provider agrees to accept Medicare assignment, they cannot charge more than the Medicare-approved amount. For you, this means your out-of-pocket costs may be lower than if you saw a provider who did not accept Medicare assignment. The provider acknowledges that the amount Medicare set for a particular service is the maximum amount that will be paid. You may still have to pay a Medicare deductible and coinsurance, but your provider will have to submit a claim to Medicare directly and wait for payment before passing any share of the costs onto you. Doctors who accept Medicare assignment cannot charge you to submit these claims.
Have questions about your Medicare coverage?
How do i know if a provider accepts medicare assignment.
- Providers who have agreed to accept Medicare assignment sign a contract with Medicare.
- Those who have not signed a contract with Medicare can still accept assignment amounts for services of their choice. They do not have to accept assignment for every service provided. These are called non-participating providers.
- Some providers opt out of Medicare altogether. Doctors who have opted out of Medicare completely or who use private contracts will not be paid anything by Medicare, even if it’s for a covered service within the fee limits. You will have to pay the full cost of any services provided by these doctors yourself.
Billing Arrangement Options for Providers Who Accept Medicare
What does it mean when a provider does not accept medicare assignment.
Providers who refuse Medicare assignment can still choose to accept Medicare’s set fees for certain services. These are called non-participating providers. There are a number of providers who opt out of participating in Medicare altogether; they are referred to as “opt-out doctors”. This means they have signed an opt-out agreement with Medicare and can’t be paid by Medicare at all — even for services normally covered by Medicare. Opt-out contracts last for at least two years. Some of these providers may only offer services to patients who sign contracts. You do not need to sign a contract with a private provider or use an opt-out provider. There are many options for alternative providers who accept Medicare. If you do choose an opt-out or private contract provider, you will have to pay the full cost of services on your own.
Do providers have to accept Medicare assignment?
How much will i have to pay if my provider doesn't accept medicare assignment, how do i submit a claim, can my provider charge to submit a claim.
- Lower Costs with Assignment. Medicare.gov.
- Fee Schedules . CMS.gov.
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Understanding Enrollment Status, Assigned vs. Non-Assigned, and the ABN
Published in Member Communities on July 23, 2021
A major part of business development is understanding your payer mix and which products and services should be reimbursable versus cash sale items. What could you bundle together in your offering to expand business—specifically items that can be sold for retail alongside your reimbursable items? You might not necessarily offer everything right now, but these are the areas you can look to expand into. This resource outlines how to navigate reimbursement to help grow your business.
Understanding the Two Types of Enrollment Status: Participating and Non-Participating
Being enrolled as a participating supplier means that the supplier accepts the Medicare fee schedule and will bill all claims on an assigned basis. Meanwhile, enrollment as a non-participating supplier means there are options for the supplier to either submit the claim on an assigned basis or on a non-assigned basis. With the current reimbursement rates, having the options for claim submission is key for maintaining business operations as well as keeping a healthy bottom line. Open enrollment is Nov. 15th through Dec. 31st for the next calendar year, so now is the time to think through your options.
It’s important for hospital-based DME suppliers to know that the enrollment status follows the tax ID. Many hospital-based DME suppliers are under the hospital’s tax ID, which means the DME supplier follows the enrollment status of the hospital which is participating. To change to non-participating status, the hospital-based DME supplier would have to get a separate tax ID.
For suppliers located within a competitive bid area (CBA), having a competitive bid contract does not direct the enrollment status. A supplier with a CB contract can be enrolled as non-participating and can submit claims as non-assigned for those items not included in competitive bid. Having a contract under the Medicare CB programs simply states a supplier must accept assignment on those products within the contract.
Suppliers located in a CBA that do not have a contract for CB items would not get reimbursed for CB items on any claim—assigned or non-assigned. If the beneficiary chooses to use a non-contracted supplier and waive their Medicare benefits, the item would be a cash transaction. In such a case, the supplier should make sure to use an Advance Beneficiary Notice of Non-Coverage (ABN).
Myths About Assignment and Non-Assignment
- A participating supplier gets reimbursed at a higher rate. False. This applies to physician services, not DMEPOS suppliers.
- There are many advantages to being enrolled as a participating supplier. False. The only reward for being enrolled as a participating supplier is getting listed in the supplier directory.
- On non-assigned claims, there is a limiting charge to the beneficiary. False. There is not a limiting charge for DMEPOS suppliers.
- With non-assigned claims, there is not any liability for the suppliers. False. The liability still exists with that claim. It does not matter if the claim is being submitted as assigned or non-assigned; the supplier can still get a denial and still get an audit on a non-assigned claim.
What Is the Purpose of the ABN?
The ABN, CMS-R-131 form, is specific to Medicare fee for service (FFS). The purpose of an ABN is to inform a beneficiary in advance (prior to delivery) of the detailed reason Medicare may not pay for the service/equipment being provided and shifting the financial liability from the supplier to the beneficiary. There are several situations in which to use an ABN
When an ABN Is Used
- Lack of medical necessity
- Same or similar equipment
- The quantity exceeds the allowed amount
- Upgrades (not within the same code)
It is important to understand that the reason for denial must be specific to the situation with that beneficiary and include detailed information.
When an ABN Would Be Considered Invalid
An ABN cannot be used across the board. That is called a blanket ABN and will end with the supplier getting backed out of the transaction and refunding money.
An ABN cannot list generic reasons for the denial, such as “Medicare may not pay for this item,” or “If there is similar equipment on file, Medicare will not pay for another one.” These are just a few examples of generic statements that can back a supplier out of transaction, essentially refunding any money paid back to Medicare and the beneficiary.
An ABN is not used for a claim that is being submitted as non-assigned. The reason for implementing an ABN for a non-assigned claim cannot be “claim is being submitted as non-assigned.” With a non-assigned claim, there still is financial liability, meaning the supplier needs to make sure the coverage criteria have been met according to the medical policy. If the coverage criteria are not met, this is when an ABN is implemented, whether it’s being submitted as an assigned claim or a non-assigned claim.
Remember, the ABN speaks to the beneficiary, making sure they understand the information documented on the form. The ABN allows the beneficiary to make an informed consumer decision about whether or not to receive the services for which they may have to pay out of pocket.
ABNs are chosen for review and audits. If not used properly and completed as instructed, an ABN will cause an unfavorable decision in an audit or be denied in a review.
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What You Need to Know About Medicare Assignment
If you are one of the more than 63 million Americans enrolled in Medicare and are on the lookout for a new provider, you may wonder what your options are. A good place to start? Weighing the pros and cons of choosing an Original Medicare plan versus a Medicare Advantage plan—both of which have their upsides.
Let’s say you decide on an Original Medicare plan, which many U.S. doctors accept. In your research, however, you come across the term “Medicare assignment.” Cue the head-scratching. What exactly does that mean, and how might it affect your coverage costs?
What is Medicare Assignment?
It turns out that Medicare assignment is a concept you need to understand before seeing a new doctor. First things first: Ask your doctor if they “accept assignment”—that exact phrasing—which means they have agreed to accept a Medicare-approved amount as full payment for any Medicare-covered service provided to you. If your doctor accepts assignment, that means they’ll send your whole medical bill to Medicare, and then Medicare pays 80% of the cost, while you are responsible for the remaining 20%.
A doctor who doesn’t accept assignment, however, could charge up to 15% more than the Medicare-approved amount for their services, depending on what state you live in, shouldering you with not only that additional cost but also your 20% share of the original cost. Additionally, the doctor is supposed to submit your claim to Medicare, but you may have to pay them on the day of service and then file a reimbursement claim from Medicare after the fact.
Worried that your doctor will not accept assignment? Luckily, 98% of U.S. physicians who accept Medicare patients also accept Medicare assignment, according to the U.S. Centers for Medicare & Medicaid Services (CMS). They are known as assignment providers, participating providers, or Medicare-enrolled providers.
It can be confusing. Here’s how to assess whether your provider accepts Medicare assignment, and what that means for your out-of-pocket costs:
The 3 Types of Original Medicare Providers
1. participating providers, or those who accept medicare assignment.
These providers have an agreement with Medicare to accept the Medicare-approved amount as full payment for their services. You don’t have to pay anything other than a copay or coinsurance (depending on your plan) at the time of your visit. Typically, Medicare pays 80% of the cost, while you are responsible for the remaining 20%, as long as you have met your deductible.
2. Non-participating providers
“Most providers accept Medicare, but a small percentage of doctors are known as non-participating providers,” explains Caitlin Donovan, senior director of public relations at the National Patient Advocate Foundation (NPAF) in Washington D.C. “These may be more expensive,” she adds. Also known as non-par providers, these physicians may accept Medicare patients and insurance, but they have not agreed to take assignment Medicare in all cases. That means they’re not held to the Medicare-approved amount as payment in full. As a reminder, a doctor who doesn’t accept assignment can charge up to 15% more than the Medicare-approved amount, depending on what part of the country you live in, and you will have to pay that additional amount plus your 20% share of the original cost.
What does that mean for you? Besides being charged more than the Medicare-approved amount, you might also be required to do some legwork to get reimbursed by Medicare.
- You may have to pay the entire bill at the time of service and wait to be reimbursed 80% of the Medicare-approved amount. In most cases, the provider will submit the claim for you. But sometimes, you’ll have to submit it yourself.
- Depending on the state you live in, the provider may also charge you as much as 15% more than the Medicare-approved amount. (In New York state, for example, that add-on charge is limited to 5%.) This is called a limiting charge—and the difference, called the balance bill, is your responsibility.
There are some non-par providers, however, who accept Medicare assignment for certain services, on a case-by-case basis. Those may include any of the services—anything from hospital and hospice care to lab tests and surgery—available from any assignment-accepting doctor, with a key exception: If a non-par provider accepts assignment for a particular service, they cannot bill you more than the regular Medicare deductible and coinsurance amount for that specific treatment. Just as it’s important to confirm whether your doctor accepts assignment, it’s also important to confirm which services are included at assignment.
3. Opt-out providers
A small percentage of providers do not participate in Medicare at all. In 2020, for example, only 1% of all non-pediatric physicians nationwide opted out, and of that group, 42% were psychiatrists. “Some doctors opt out of providing Medicare coverage altogether,” notes Donovan.“In that case, the patient would pay privately.” If you were interested in seeing a physician who had opted out of Medicare, you would have to enter a private contract with that provider, and neither you nor the provider would be eligible for reimbursement from Medicare.
How do I know if my doctor accepts Medicare assignment?
The best way to find out whether your provider accepts Medicare assignment is simply to ask. First, confirm whether they are participating or non-participating—and if they are non-participating, ask whether they accept Medicare assignment for certain services.
Also, make sure to ask your provider exactly how they will be billing Medicare and what charges you might expect at the time of your visit so that you’re on the same page from the start.
Is seeing a non-participating provider who accepts Medicare assignment more expensive?
The short answer is yes. There are usually out-of-pocket costs after you’re reimbursed. But it may not cost as much as you think, and it may not be much more than if you see a participating provider. Still, it could be challenging if you’re on a fixed income.
For example, let’s say you’re seeing a physical therapist who accepts Medicare patients but not Medicare assignment. Medicare will pay $95 per visit to the provider; but your provider bills the service at $115. In most states, you’re responsible for a 15% limiting charge above $95. In this case, your bill would be 115% of $95, or $109.25.
Once you get your $95 reimbursement back from Medicare, your cost for the visit—the balance bill—would be $14.25 (plus any deductibles or copays) .
In some states, the maximum cap on the limiting charge is less than 15%. As mentioned earlier, New York state, for instance, allows only a 5% surcharge, which means that physical therapy appointment would cost you just $4.75 extra.
Bottom line: Medicare assignment providers and non-participating providers who agree to accept Medicare assignment are both viable options for patients. So if you want to see a particular provider, don’t rule them out just because they’re non-par.
While seeing a non-participating provider may still be affordable, ultimately, the biggest headache may be keeping track of claims and reimbursements, or simply setting aside the right amount of money to pay for your visit up front.
Before you schedule a visit, be sure to ask how much the service will cost. You can also estimate the payment amount based on Medicare-approved charges. A good place to start is this out-of-pocket expense calculator provided by the CMS.
What if I see a provider who opts out of Medicare altogether?
An opt-out provider will create a private contract with you, underscoring the terms of your agreement. But Medicare will not reimburse either of you for services.
Seeing a provider who does not accept Medicare will likely be more expensive. And your visits won’t count toward your deductible. But you may be able to work out paying reduced fees on a sliding scale for that provider’s services, all of which would be laid out in your contract.
Medicare Assignment: Understanding How It Works
Medicare assignment is a term used to describe how a healthcare provider agrees to accept the Medicare-approved amount. Depending on how you get your Medicare coverage, it could be essential to understand what it means and how it can affect you.
What is Medicare assignment?
Medicare sets a fixed cost to pay for every benefit they cover. This amount is called Medicare assignment.
You have the largest healthcare provider network with over 800,000 providers nationwide on Original Medicare . You can see any doctor nationwide that accepts Medicare.
Understanding the differences between your cost and the difference between accepting Medicare and accepting Medicare assignment could be worth thousands of dollars.
Doctors that accept Medicare
Your healthcare provider can fall into one of three categories:
Medicare participating provider and Medicare assignment
Medicare participating providers not accepting medicare assignment, medicare non-participating provider.
More than 97% of healthcare providers nationwide accept Medicare. Because of this, you can see almost any provider throughout the United States without needing referrals.
Let’s discuss the three categories the healthcare providers fall into.
Participating providers are doctors or healthcare providers who accept assignment. This means they will never charge more than the Medicare-approved amount.
Some non-participating providers accept Medicare but not Medicare assignment. This means you can see them the same way a provider accepts assignment.
You need to understand that since they don’t take the assigned amount, they can charge up to 15% more than the Medicare-approved amount.
Since Medicare will only pay the Medicare-approved amount, you’ll be responsible for these charges. The 15% overcharge is called an excess charge. A few states don’t allow or limit the amount or services of the excess charges. Only about 5% of providers charge excess charges.
Opt-out providers don’t accept Original Medicare, and these healthcare providers are in the minority in the United States. If healthcare providers don’t accept Medicare, they won’t be paid by Medicare.
This means choosing to see a provider that doesn’t accept Medicare will leave you responsible for 100% of what they charge you. These providers may be in-network for a Medicare Advantage plan in some cases.
Avoiding excess charges
Excess charges could be large or small depending on the service and the Medicare-approved amount. Avoiding these is easy. The simplest way is to ask your provider if they accept assignment before service.
If they say yes, they don’t issue excess charges. Or, on Medicare.gov , a provider search tool will allow you to look up your healthcare provider and show if they accept Medicare assignment or not.
Medicare Supplement and Medicare assignment
Medigap plans are additional insurance that helps cover your Medicare cost-share . If you are on specific plans, they’ll pay any extra costs from healthcare providers that accept Medicare but not Medicare assigned amount. Most Medicare Supplement plans don’t cover the excess charges.
The top three Medicare Supplement plans cover excess charges if you use a provider that accepts Medicare but not Medicare assignment.
Medicare Advantage and Medicare assignment
Medicare assignment does not affect Medicare Advantage plans since Medicare Advantage is just another way to receive your Medicare benefits. Since your Medicare Advantage plan handles your healthcare benefits, they set the terms.
Most Medicare Advantage plans require you to use network providers. If you go out of the network, you may pay more. If you’re on an HMO, you’d be responsible for the entire charge of the provider not being in the network.
Do all doctors accept Medicare Supplement plans?
All doctors that accept Original Medicare accept Medicare Supplement plans. Some doctors don’t accept Medicare. In this case, those doctors won’t accept Medicare Supplements.
Where can I find doctors who accept Medicare assignment?
Medicare has a physician finder tool that will show if a healthcare provider participates in Medicare and accepts Medicare assignments. Most doctors nationwide do accept assignment and therefore don’t charge the Part B excess charges.
Why do some doctors not accept Medicare?
Some doctors are called concierge doctors. These doctors don’t accept any insurance and require cash payments.
What is a Medicare assignment?
Accepting Medicare assignment means that the healthcare provider has agreed only to charge the approved amount for procedures and services.
What does it mean if a doctor does not accept Medicare assignment?
The doctor can change more than the Medicare-approved amount for procedures and services. You could be responsible for up to a 15% excess charge.
How many doctors accept Medicare assignment?
About 97% of doctors agree to accept assignment nationwide.
Is accepting Medicare the same as accepting Medicare assignment?
No. If a doctor accepts Medicare and accepts Medicare assigned amount, they’ll take what Medicare approves as payment in full.
If they accept Medicare but not Medicare assignment, they can charge an excess charge of up to 15% above the Medicare-approved amount. You could be responsible for this excess charge.
What is the Medicare-approved amount?
The Medicare-approved amount is Medicare’s charge as the maximum for any given medical service or procedure. Medicare has set forth an approved amount for every covered item or service.
Can doctors balance bill patients?
Yes, if that doctor is a Medicare participating provider not accepting Medicare assigned amount. The provider may bill up to 15% more than the Medicare-approved amount.
What happens if a doctor does not accept Medicare?
Doctors that don’t accept Medicare will require you to pay their full cost when using their services. Since these providers are non-participating, Medicare will not pay or reimburse for any services rendered.
Get help avoiding Medicare Part B excess charges
Whether it’s Medicare assignment, or anything related to Medicare, we have licensed agents that specialize in this field standing by to assist.
Give us a call, or fill out our online request form . We are happy to help answer questions, review options, and guide you through the process.
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- Medicare Assignment
Home / Medicare101 / How Much Does Medicare Cost / Medicare Assignment
- Updated on March 31, 2023
- Written By: David Haass
- Reviewed By: Ashlee Zareczny
Once you have Original Medicare, ask your doctor if they accept Medicare assignment before receiving services. This is because doctors who accept Medicare assignment are agreeing to the terms of the Medicare program, and those who don’t can leave you paying higher costs for your healthcare.
The good news is that there are more than 800,000 doctors nationwide who accept Medicare assignment, making it the largest provider network in the United States. Whether you want to see the best doctor while on vacation or your local healthcare provider, chances are they’re in-network.
When it comes to healthcare facilities, knowing which accepts Medicare assignment and how you’re affected by such designation is essential. The difference can mean hundreds if not thousands of dollars in healthcare costs or savings. Learn more about doctors who accept Medicare assignment, how the system works, and the status maintained by many popular healthcare facilities.
What is Medicare Assignment?
Medicare assignment is a fee schedule agreement between the federal government’s Medicare program and a doctor or facility. When Medicare assignment is accepted, it means your doctor agrees to the payment terms of Medicare.
Doctors that accept Medicare assignment fall under one of three designations: a participating doctor, a non-participating doctor, or they opt-out of the program altogether. Let’s break down the various designation of Medicare assignment providers below:
- Participating Providers: Providers that accept Medicare assignment and agree to accept what Medicare establishes per procedure, or visit, as payment in full.
- Non-Participating Providers: Providers who accept Medicare benefits, but do not accept the amount Medicare says a procedure or visit should cost. These providers reserve the right to charge an excess charge of up to 15% more than the Medicare-approved amount in states that allow it.
- Opt-Out Providers: The minority of healthcare providers that do not accept Medicare. Fortunately for beneficiaries, this group represents less than 3% of adult healthcare providers in the United States.
How To Find Out if a Doctor Accepts Medicare Assignment
Since not every doctor accepts Medicare assignment, it’s important to know whether or not your doctor does. You can easily pinpoint and compare doctors that accept Medicare assignment of benefits with the Care Compare Tool . The tool allows you to personalize results for doctors and hospitals in your area. Also, the tool is available on smartphones and tablets.
Using the Care Compare Tool provides you with much more information than which providers who do not accept assignment of Medicare benefits or do accept it. You can also find out important information such as contact info, quality ratings, and directions to healthcare facilities.
Furthermore, you can also use the Care Compare Tool to find out information on nursing homes, hospices, dialysis centers, rehab care, and Long-Term care facilities.
Do All Doctors Accept Medicare Supplement Plans?
All doctors who accept Original Medicare will accept Medicare Supplement plans. However, not all doctors accept the federal government’s Medicare program.
Also known as Medigap, your Medicare Supplement benefits are there to help you cover the leftover costs that can occur when using Original Medicare benefits alone. Therefore, while you have access to every doctor in America that accepts Medicare, if they don’t, you’ll need to pay for your healthcare costs out of your own pocket.
One common mistake you may encounter is receiving healthcare services only to be told at the desk that the facility doesn’t accept your Medigap plan. There are 12 lettered Medicare Supplement plans available, but all are accepted at any healthcare facility accepting Medicare assignment. The misconception can occur when workers confuse the idea of networks. Medigap doesn’t have networks, but Medicare Advantage plans do.
Overall, if you encounter such issues, simply ask if the facility accepts Medicare. If the answer is yes, you’ll be covered by your Medicare Supplement benefits also. However, if you are enrolled in a Medicare Advantage plan, you’ll need to also be sure that the facility is within your plan’s network. While out-of-network healthcare providers may still be used by Medicare Advantage beneficiaries, the cost will be higher.
Do Most Doctors Accept Medicare Assignment?
An overwhelming majority of doctors are healthcare providers which adhere to Medicare assignment rules. Around 98% of all doctors providing healthcare to adults are either participating or non-participating providers. Remember, even non-participating providers accept Medicare. They simply reserve the right to charge as much as 15% more through Medicare Part B excess charges in states that allow them.
This is great news for beneficiaries enrolled in Medicare because it provides more options for healthcare and benefits. Rather than facing expensive, rising healthcare costs alone, you can enjoy benefits that help you cover the costs of approved services.
But it’s important to understand that different Medicare benefits may have some restrictions. Specifically, when enrolled in Medicare Advantage plans, you’ll need to ensure that they are in your plan’s network.
For many, this can be a restriction that only allows healthcare services near one’s home. Meaning if you’re known to travel, it may not be the best choice for you. Because Medicare Supplement plans don’t have a network, all you’ll need to worry about is whether or not your healthcare provider accepts Medicare assignments or not to be covered, regardless of location within the United States.
What Happens if a Doctor Doesn’t Accept Medicare Assignment?
Providers who do not accept Medicare Assignment may require you to pay higher costs for services out-of-pocket. You could pay up to an additional 15% of the Medicare-approved amount out-of-pocket, then wait for Medicare reimbursement, but there’s no reimbursement guarantee.
If you are receiving healthcare from doctors who opt-out of Medicare services, you’ll pay 100% of the costs. But unlike Medicare assignment doctors, these healthcare providers don’t set their fees to Medicare standards. This means you may pay more as a result, and that is exactly why you should always confirm first whether your doctor accepts the assignment or not.
After you receive services from a doctor who doesn’t accept the assignment but is still part of the Medicare program, you can receive reimbursement. But you must file a claim to Medicare asking for reimbursement by filling out the CMS-1490S form to ask for payment. The service provider will likely process the claim, then deal with Medicare to help you get reimbursement. Alternatively, if they do not, then you also have the option to process your claim.
Medicare Opt-Out Private Contract
A Medicare opt-out private contract may come to be if your doctor does not have an agreement with Medicare and asks you to sign a private contract. Once you sign a contract, you accept the total amount of your healthcare costs on your own, and Medicare can’t reimburse you. Signing such a contract gives up your right to use Medicare for your health purposes.
Before you sign a private contract, you should know the following:
- Medicare can’t reimburse you for healthcare services.
- Medicare can’t pay for your services.
- You can pay for services whenever you want without signing a Medicare opt-out private contract.
- The service provider sets the prices for your healthcare.
These considerations are important because the cost of handling your healthcare costs alone can be monumental for anyone. While each situation is different, avoiding Medicare opt-out private contracts and using providers who accept Medicare assignment instead can help you receive the services you deserve while protecting your finances.
Do Hospitals Accept Medicare Assignment?
Most hospitals accept Medicare assignment. For general purposes, hospitals are similar to Medicare doctors who accept assignment, meaning the following:
- Most facilities are going to accept Medicare.
- Because hospitals accept Medicare assignment, you’re covered for both your Part A and Part B services.
- Although a large majority of hospitals accept Medicare assignment, not all do, and you’re going to need to check with a facility before receiving healthcare from them to understand where they stand.
- Excess charges can still exist in states that allow them, allowing for Part B costs to be elevated by as much as 15%.
- If you have Medicare Advantage benefits, you’re going to need to receive services from hospitals within your network or pay for your healthcare yourself. Alternatively, if you have a Medicare PPO plan, you may be able to use an out-of-network hospital, but you’ll pay a lot more.
Remember, if Original Medicare benefits are accepted, so too is your Medigap coverage. Therefore, you’ll need to take into consideration your lifestyle, finances, travel plans, and other personal factors before enrolling in either a Medicare Advantage or Medigap plan. Speaking with a licensed Medicare agent can help you navigate Medicare assignment and your coverage.
Does Cleveland Clinic Accept Medicare Assignment?
Yes, Cleveland Clinic accepts Medicare assignment at most of its 22 hospitals and 275 outpatient locations. This means if you have benefits from Original Medicare, Medicare Supplement, and/or Medicare Advantage, they are accepted so long as the facility is within the United States of America. Furthermore, you’ll still need to determine whether or not a specific location is within your plan’s network for Medicare Advantage benefits.
Does CVS Accept Medicare Assignment?
Yes, the various CVS Health businesses, including MinuteClinic, all accept Medicare assignment in the United States. Again, you’ll still need to ensure that specific locations are a part of your Medicare Advantage plan before using your benefits. While Medicare assignment is unrelated to Medicare Part D , you will find that most Part D plans are also accepted by CVS Pharmacy, though this may vary by location with America’s largest pharmacy retailer.
Does Labcorp Accept Medicare Assignment?
Yes, Labcorp accepts Medicare assignment throughout its more than 2,000 locations found within the U.S. The same guidelines apply. Both Original Medicare and Medigap benefits are accepted, along with Medicare Advantage. But your Advantage benefits will also consider whether or not the location you are going to is a part of your plan’s network.
Does Mayo Clinic Accept Medicare Assignment?
No, while Mayo Clinic does accept Medicare benefits within the 44 communities in which they are present, the campuses do not accept Medicare assignment. This means if you receive healthcare at a Mayo Clinic location, you’ll be billed, and you may be charged a higher rate due to excess charges. Of course, the best way to understand a specific location’s billing is to contact your local campus directly. This is especially important for those with Medicare Advantage plans who will also need to make sure their local Mayo Clinic is within their Advantage plan’s network.
Does MD Anderson Accept Medicare Assignment?
Yes, MD Anderson consists of hospitals that accept Medicare assignment, meaning you can use your benefits at its 13 hospital systems throughout 11 states. What you need to realize is that while benefits for Original Medicare and Medigap are accepted, MD Anderson’s Medicare Advantage options are quite limited. Furthermore, it is advised that you speak with your plan provider before receiving healthcare from the Houston-based healthcare provider.
Does Walgreens Accept Medicare Assignment?
Yes, Walgreens accepts Medicare assignment, allowing its customers to find affordable healthcare solutions near their homes. As the second-largest pharmacy brand in the U.S., you can also take advantage of your Medicare Part D benefits, along with many services covered by Part B coverage. Featuring more than 9,000 stores nationwide, remember to check your plan’s network if you have Medicare Advantage coverage to ensure that you are covered before you go.
What is Medicare Assignment of Benefits?
The assignment of benefits is when the insured authorizes Medicare to reimburse the provider directly. In return, the provider agrees to accept the Medicare charge as the full charge for services. Non-participating providers can accept assignments on an individual claims basis. On item 27 of the CMS-1500 claim form, Medicare assignment of benefits requirements dictate that non-participating doctors check “yes” when they agree to accept Medicare assignment for the full charge on the claim.
What are Medicare Assignment Codes?
The Medicare assignment code is what shows proof that Medicare has agreed to represent you and cover your medical bills. This method allows for easy communication between health providers and Medicare when caring for your medical needs.
Participating healthcare providers file for service reimbursement with a Medicare assignment of benefits form. Formally known as a CMS-1500 form , this is used by non-institutional providers and suppliers for reimbursement from Medicare and, in some cases, Medicare State Agencies.
What is Medicare Part B Assignment?
Medicare Part B assignment is when your doctor accepts the preassigned costs for Medicare outpatient services. Participating providers determine how much you pay for Part B services. For example, fully participating doctors accept Medicare rates for services, meaning you only pay 20% of the bill with Original Medicare. However, if a provider is not participating, you could be responsible for an excess charge of 15%.
Some providers refuse Medicare assignment altogether. If this is the situation, you’re responsible for 100% of the costs not only for Medicare Part B but also for Part A services if they apply.
What Is the Difference Between Medicare Participation and Assignment?
Being a participant in Medicare assignment varies from accepting assignment because non-participating providers can still accept but charge more. Remember, this is where excess charges come into play unless you are in Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, or Vermont, which all prevent such charges.
An excess charge means that a healthcare provider can charge you as much as 15% more than Medicare for approved services. Therefore, just because a healthcare provider accepts Medicare assignment, doesn’t mean they are a Par Provider, and you may face higher rates even with coverage.
What Is a Par Provider?
A Par Provider is the same as a Participating Provider. These healthcare providers have accepted assignment from Medicare and agree to charge the amount allowable according to the federal government’s program for approved services. If you receive care from Par Physicians, you may still have out-of-pocket costs, which can be covered partially or entirely by Medicare Supplement plans.
How To Navigate Medicare Assignment and Your Benefits
The best way to avoid excess charges if you live in one of the many states that allow them is by visiting a provider who accepts Medicare and participates in Medicare assignment. But as you can see, additional considerations come into play.
Keeping your healthcare costs in check while receiving the right services is a delicate balancing act. Original Medicare is a robust coverage, but covering additional costs can often be tricky. Many options are available, and you can only have Medigap or Medicare Advantage.
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17 thoughts on " medicare assignment ".
I have just reached 65 and am now covered by Medicare part A and B. I have made an appointment on my own with my local Diagnostic Center for a yearly mammogram that I have not had in years. Do I need my doctor to make that referral on my behalf for Medicare to pick up the cost? Is the total cost covered by Medicare or is it subject to the Medicare deductible being met and then they pay their 80%? Is the 3D mammogram covered which is more comprehensive since I have had a biopsy in the past and need the more comprehensive xray? Thank you for your assistance!
Hello! Your coverage will be determined by the type of mammogram you receive. If the mammogram is diagnostic, you will be subject to the 20% co-payment. If this is a preventative mammogram, you will receive 100% coverage as long as your provider accepts Original Medicare.
I think there are procedures which Medicare does not cover. If doctor which accept assignment who orders non-Medicare approved procedure, is patient responsible for that procedure that was ordered by doctor and not covered by Medicare. Or is doctor legally obligated to inform the patient that the procedure is not covered?
Bill, it is up to you to know what is and is not covered by your insurance. However, the doctor should inform you that it will not be covered by Medicare and you will be required to sign an Advanced Beneficiary Notice. This waiver informs you that Medicare may not cover the services and you will pay out-of-pocket if Medicare denies the claim.
We accept Medicare but claims were denied because it’s under capitation what does it means. Who’s is payer insurance of the services. This is a solo medical practice
Hi Ray! You can read more on Capitated Model here .
Hello Lindsay,
I work for a provider that accepts Medicare, however we do balance bill. Is there a difference between Medicare and Medicare assigment? Are they in fact 2 different programs? We have conflicting information and want to clear this up.
Hi Amy! You can accept Medicare, but be a non-participating provider. This means you do accept Medicare, but you do not accept the Medicare-approved amount for a service. Non-participating providers can balance bill up to 15% of the Medicare-approved amount for the service. I wouldn’t say it’s two different programs but one of three billing arrangement options for providers who accept Medicare. I hope this helped clarify!
Hi! So how does the non participation but accepting Medicare work for Annual Wellness Visits? Is it still appropriate to have non-par providers who accept assignment billing for AWVs? Also, do Medicare Advantage companies allow for non-par/accepting assignment providers to bill as well? Last question….do these providers still need to be fully credentialed if they are non par for Medicare? Assume yes, but wasn’t sure how Medicare and even insurance companies view this. For example if I am using a vendor to arrange for providers to help complete AWV’s and those providers are non par but accept assignment is that acceptable for a MA plan where providers do need PTAN’s.
Hey Jagger, I will be starting Medicare soon. The chiropractor. I see can’t accept Medicare because he can’t find anyone to do Medicare billing. He has been my god sent for adjustments for over 10 years. I would gladly pay him out of my own pocket, before switching to someone I don’t know, and doesn’t know my needs. Is it possible to stay with my doc? Linda
Hi Linda – if your doctor doesn’t accept Medicare but is still part of the Medicare program, you can fill out Form CMS 1490S to request medical payment. Otherwise, you can pay out-of-pocket while still being on Medicare.
Hi, Lindsay, my wife received a Medicare Claim Notice for care she received from a non-participating provider (my wife paid the entire claimed amount at the time of the appointment). One note on the claim notice said, “Under federal law, your doctor cannot charge more than $38.34. If you have already paid more than this amount, you are entitled to a refund from the provider.” The provider refuses to refund us the $61.66 overpayment my wife paid. I called Medicare, and they don’t care. Who can we report this to?
Hi William! Your best bet is to call Medicare. However, since you’ve already gone that route and had no luck, I would contact your carrier directly. Have them put in writing & document what their responsibility is and the overpayment to provide to the doctor. Hopefully, that will get their attention.
If a doctor accepts assignment, can they balance bill the patient?
Hi Elizabeth! If they accept Medicare Assignment, the doctor can only bill the amount Medicare has approved. If you don’t have any supplemental insurance, Medicare will bill you the remaining amount after they cover their portion of the costs. If the doctor does not accept Medicare Assignment, they can bill you up to 15% in excess charges for each service.
Hello Lindsay. My doctors office says they accept medicaid. Does that mean they accept medicare? I have plan N with Cigna.
Hi Thomas! Medicare & Medicaid are two different types of health coverage. However, I would imagine if your doctor accepts Medicaid, they probably accept Medicare. I would just give them a call to verify.
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What the 3 Types of Health Care Providers Mean for Medicare Beneficiaries
- Ann Kayrish Senior Program Manager, for Medicare
Related Topics
- Physical Health for Older Adults
If you are enrolled in Original Medicare (Parts A & B) , it is important to understand the relationship your health care providers have with Medicare. This relationship can directly impact what you pay for certain Medicare services.
Under Original Medicare, your doctors and health care facilities can have one of three relationships with Medicare:
- A participating provider
- A non-participating provider
- An opt-out provider
What is a participating provider under Medicare?
A participating provider has signed up to accept Medicare insurance and agrees to always "accept assignment." A doctor that accepts assignment agrees to accept the Medicare-approved amount as full payment for any Medicare-covered service.
As the patient of a participating Medicare provider, you can expect:
- You will not have to handle the billing paperwork. Your provider will submit your claims to Medicare on your behalf, and Medicare will process the bill and pay the provider directly.
- Once you meet your Medicare Part B deductible, Medicare will pay 80% of the approved amount, and you will be responsible for paying the 20% coinsurance.
- Many Medicare supplement plans (also called Medigap) will cover the 20% you may owe. Consult your Medigap plan for details.
What is a non-participating provider under Medicare?
A non-participating provider has agreed to accept Medicare insurance but not accept assignment. Consequently, non-participating providers may charge up to 15% above the Medicare approved amount for the Medicare-covered service. This extra payment is called the limiting charge. Note that this 15% charge is based on Medicare’s fees for a service amount and not on the amount the provider originally charged.
As the patient of a non-participating provider, you can expect that:
- The provider may require you to pay the entire charge at the time of service.
- Once you meet your Medicare Part B deductible, Medicare will pay their portion based on Medicare’s fee schedule, and you will be responsible to pay up to 35% (20% coinsurance + 15% limiting charge) of Medicare’s approved amount for covered services.
- You may need to file a claim directly with Medicare if the provider does not choose to submit a claim (that is, bill Medicare directly) on your behalf. You can file a claim with Medicare by completing the Patient’s Request for Payment Form CMS-1490S
- Many Medicare supplement/Medigap plans will cover the coinsurance, and some will even cover the limiting/excess charges. Consult your plan policy for details.
What is an opt-out provider under Medicare?
Opt-out providers choose not to work with Medicare insurance. Medicare will not pay for any covered items or services provided by opt-out doctors or other healthcare professionals, except in the case of an emergency or urgent need. Opt-out providers and patients set up mutually agreed upon payment terms under a private contract.
If you are a patient of an opt-out physician, you can expect that:
- The provider will bill you directly for care and services, and you will pay out-of-pocket.
- Neither you nor the provider will submit a bill nor receive reimbursement from Medicare. Opt-out providers are not governed by Medicare’s set fees.
- Most Medicare supplemental policies do not cover services provided by an opt-out provider. Be sure to check your policy for details.
What does this mean if I have Medicare Advantage?
If you’re enrolled in a Medicare Advantage plan , you pay the specific co-pays for doctors’ services that your plan requires. You usually must see a provider within your plan network.
How do I find more information about my health care providers?
It is always a good idea to contact your provider directly if you have questions about their education, board certification, or Medicare provider status. Medicare also offers several tools to help you learn more about the providers currently coordinating your care.
- Use Medicare’s Physician Compare tool to determine whether your provider is participating, non-participating, or an opt-out Medicare provider.
- Find a physician’s board certifications, education, states with active licenses, and any actions against them using the search on DocInfo.org from the Federation of State Medical Boards.
- Medicare’s open payment search tool can be used to search for payments made by drug and medical device companies to physicians, teaching hospitals, and physician assistants.
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- Introduction
- Conclusions
- Article Information
DLQI indicates Dermatology Life Quality Index; PGA, Physician Global Assessment.
Trial Protocol
eAppendix. LITE Study Site Investigators and Stakeholders
eFigure 1. Study Design
eFigure 2. Sensitivity Analyses for Co-Primary Endpoints
eFigure 3. Tipping Point Analysis, Missing Outcomes in Home Phototherapy Group Imputed as Non-Responders
eFigure 4. Tipping Point Analysis, Missing Outcomes in Home Phototherapy Group Imputed at Observed Response Rate
eTable 1. Co-Primary Endpoints, Response Rates at Week 12, Tests of Superiority
eTable 2. Sensitivity Analyses of Primary Outcomes
eReferences
Data Sharing Statement
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Gelfand JM , Armstrong AW , Lim HW, et al. Home- vs Office-Based Narrowband UV-B Phototherapy for Patients With Psoriasis : The LITE Randomized Clinical Trial . JAMA Dermatol. Published online September 25, 2024. doi:10.1001/jamadermatol.2024.3897
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Home- vs Office-Based Narrowband UV-B Phototherapy for Patients With Psoriasis : The LITE Randomized Clinical Trial
- 1 Department of Dermatology, University of Pennsylvania, Philadelphia
- 2 Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- 3 Division of Dermatology, Department of Medicine, University of California, Los Angeles
- 4 Department of Dermatology, Henry Ford Health, Detroit, Michigan
- 5 Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
- 6 Johnson Dermatology, Fort Smith, Arizona
- 7 MD Claiborne & Associates Dermatology, New Orleans, Louisiana
- 8 Department of Dermatology, SUNY at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York
- 9 Deparment of Dermatology, SUNY Downstate Health Sciences University, Brooklyn, New York
- 10 Department of Dermatology, Mayo Clinic, Scottsdale, Arizona
- 11 Department of Dermatology, University of Virginia Health System, Charlottesville
- 12 Department of Dermatology, University of California, San Francisco
- 13 Department of Dermatology, University of New Mexico, Albuquerque
- 14 Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York City, New York
- 15 Dawes Fretzin Dermatology Group, Indianapolis, Indiana
- 16 Department of Dermatology, Indiana University School of Medicine, Indianapolis
- 17 Total Dermatology, Birmingham, Alabama
- 18 Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison
- 19 Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus
- 20 MI Skin Center, Northville, Michigan
- 21 Patient advocate and LITE study stakeholder committee member, Atlanta, Georgia
- 22 Patient advocate and LITE study stakeholder committee member, Melbourne, Florida
- 23 MIT Sloan School of Management, Cambridge, Massachusetts
- 24 University of Utah Health Plans, Murray
- 25 National Psoriasis Foundation, Alexandria, Virginia
- 26 Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
- 27 Department of Dermatology, University of Utah School of Medicine, Salt Lake City
Question Is narrowband UV-B phototherapy for the treatment of plaque or guttate psoriasis at home noninferior to office-based phototherapy according to outcomes that matter to patients, physicians, and payers?
Findings In this randomized clinical trial of 783 patients with plaque or guttate psoriasis, home-based phototherapy was noninferior to office-based phototherapy across all skin tones for physician- and patient-reported outcomes and was associated with a lower burden of indirect costs to patients.
Meaning Home-based phototherapy is as effective as office-based phototherapy for psoriasis in everyday clinical practice and has less burden to patients.
Importance Office-based phototherapy is cost-effective for psoriasis but difficult to access. Home-based phototherapy is patient preferred but has limited clinical data, particularly in patients with darker skin.
Objective To compare the effectiveness of home- vs office-based narrowband UV-B phototherapy for psoriasis.
Design, Setting, and Participants The Light Treatment Effectiveness study was an investigator-initiated, pragmatic, open-label, parallel-group, multicenter, noninferiority randomized clinical trial embedded in routine care at 42 academic and private clinical dermatology practices in the US. Enrollment occurred from March 1, 2019, to December 4, 2023, with follow-up through June 2024. Participants were 12 years and older with plaque or guttate psoriasis who were candidates for home- and office-based phototherapy.
Interventions Participants were randomized to receive a home narrowband UV-B machine with guided mode dosimetry or routine care with office-based narrowband UV-B for 12 weeks, followed by an additional 12-week observation period.
Main Outcomes and Measures The coprimary effectiveness outcomes were Physician Global Assessment (PGA) dichotomized as clear/almost clear skin (score of ≤1) at the end of the intervention period and Dermatology Life Quality Index (DLQI) score of 5 or lower (no to small effect on quality of life) at week 12.
Results Of 783 patients enrolled (mean [SD] age, 48.0 [15.5] years; 376 [48.0%] female), 393 received home-based phototherapy and 390 received office-based phototherapy, with 350 (44.7%) having skin phototype (SPT) I/II, 350 (44.7%) having SPT III/IV, and 83 (10.6%) having SPT V/VI. A total of 93 patients (11.9%) were receiving systemic treatment. At baseline, mean (SD) PGA was 2.7 (0.8) and DLQI was 12.2 (7.2). At week 12, 129 patients (32.8%) receiving home-based phototherapy and 100 patients (25.6%) receiving office-based phototherapy achieved clear/almost clear skin, and 206 (52.4%) and 131 (33.6%) achieved DLQI of 5 or lower, respectively. Home-based phototherapy was noninferior to office-based phototherapy for PGA and DLQI in the overall population and across all SPTs. Home-based phototherapy, compared to office-based phototherapy, was associated with better treatment adherence (202 patients [51.4%] vs 62 patients [15.9%]; P < .001), lower burden of indirect costs to patients, and more episodes of persistent erythema (466 of 7957 treatments [5.9%] vs 46 of 3934 treatments [1.2%]; P < .001). Both treatments were well tolerated with no discontinuations due to adverse events.
Conclusions and Relevance In this randomized clinical trial, home-based phototherapy was as effective as office-based phototherapy for plaque or guttate psoriasis in everyday clinical practice and had less burden to patients.
Trial Registration ClinicalTrials.gov Identifier: NCT03726489
Psoriasis is a common, chronic, inflammatory skin disease associated with psoriatic arthritis, premature atherosclerosis, metabolic disorders, and health-related quality of life (HRQOL) impairment. 1 - 5 Patients with psoriasis have an increased risk of mortality, primarily from excess major cardiovascular events, culminating in a 5-year decrease in life expectancy for those with moderate to severe disease. 6 - 8 In the past 2 decades, there have been dramatic advances in psoriasis treatment with the advent of immune-targeted topical, oral, and injectable biologic therapies. 9 Despite these advances, patients struggle to obtain or maintain therapeutic control due to only partial effectiveness, loss of effect over time, discontinuation due to adverse effects like infection, poor adherence, or a multitude of access and cost issues. 10 - 13 Moreover, many patients with psoriasis prefer nonpharmaceutical approaches. 14
Narrowband 311 nanometer UV-B phototherapy has been a standard psoriasis treatment for decades. 15 It is often preferred due to a lack of systemic adverse effects and does not appear to increase skin cancer risk. 16 - 18 Clinical trials of office-based narrowband UV-B have demonstrated similar clinical responses to the biologic adalimumab but with better responses on measures of HRQOL, a lower risk of adverse events (particularly infection) compared to secukinumab, and improvement in systemic inflammatory (ie, reduction in C-reactive protein and interleukin 6) and lipid markers (improvement in high-density lipoprotein particle levels) relevant to cardiovascular disease compared to placebo. 16 , 19 , 20 Moreover, in the US, office-based phototherapy is 10 to 100 times less expensive per response than biologics for psoriasis. 21 Cost-effectiveness is increasingly important as US pharmaceutical expenditures for psoriasis rise dramatically, including to more than $27 billion in 2023. 22
The safety, efficacy, and health care system cost advantages of office-based phototherapy are offset by its inconvenience (patients need to receive treatments 2-3 times per week for about 12 weeks for initial clearance, often followed by treatment at a reduced frequency to maintain results), relatively high direct (ie, co-payments) and indirect (ie, travel, time off from work) costs to patients, and uneven geographic availability. 23 Home-based phototherapy uses similar light sources as office-based phototherapy and overcomes many of the limitations of office-based treatment. However, limited data on home-based phototherapy effectiveness in diverse populations have contributed to poor insurance coverage and health care professionals being uncertain about prescribing it. 15 To address this evidence gap, we conducted a randomized pragmatic trial of home- vs office-based phototherapy embedded in routine care of patients with psoriasis.
The Light Treatment Effectiveness (LITE) study was an investigator-initiated, pragmatic, open-label, parallel-group, multicenter, noninferiority randomized clinical trial. Pragmatic trials are designed to determine how well interventions work under everyday conditions and, thus, reflect clinical practice. 24 LITE was designed and executed with patients and stakeholders (the National Psoriasis Foundation, payers, and experts) from inception through dissemination.
The institutional review board of the University of Pennsylvania oversaw the conduct of the trial, approved the protocol, and was the institutional review board of record for all sites. The study was conducted according to the Declaration of Helsinki and Good Clinical Practice guidelines. Written informed consent was obtained from each participant or their parent/guardian. This study followed the Consolidated Standards of Reporting Trials ( CONSORT ) reporting guidelines.
Patients from 42 academic and private dermatology practices in the US were recruited during routine care between March 1, 2019, and December 4, 2023. Patients were eligible if they were 12 years or older with plaque or guttate psoriasis, considered a candidate for phototherapy, and deemed willing and able to comply with either in-office or in-home phototherapy. Patients previously unresponsive to phototherapy, who received phototherapy within 14 days of the baseline visit, or who were deemed medically unsuitable for phototherapy were excluded. There were no washouts or prohibited therapies. Race and ethnicity were self-reported by patients.
Patients randomized to office-based phototherapy received treatment based on local standard of care. Sites were encouraged, but not mandated, to use current guidelines for dosing phototherapy (see the study protocol in Supplement 1 ). 15 The initial dose was based on skin phototype (SPT; I/II, fair skin that burns easily and tans poorly; III/IV, darker white to light brown skin that tans easily and occasionally burns; and V/VI, brown or black skin that tans deeply and rarely burns) and was increased based on response to, and time since, the last dose. Patients randomized to home-based phototherapy received a Daavlin 7 series 8-bulb narrowband UV-B unit with guided mode dosimetry. The home phototherapy device uses the same protocol as American Academy of Dermatology/National Psoriasis Foundation psoriasis guidelines and can be customized by the prescribing clinician. 15 Similar to office treatment, the patient needs to answer a question on the home phototherapy controller about degree and duration of redness that occurred with the previous treatment. The device then delivers the appropriate protocol-defined dose. The device limits the frequency and number of treatments a patient can receive, thereby preventing misuse. During the screening period, patients provided consent, and insurance authorization for office-based phototherapy was obtained. Patients then reconfirmed willingness to be randomized based on their potential costs. The intervention period started on the date of the first treatment (or 14 days after randomization, whichever came first) and continued for 12 weeks (eFigure 1 in Supplement 2 ). Clinical assessments occurred at baseline and either at the end of treatment or the week 12 visit, whichever occurred first. The observation period started 12 weeks after the first treatment (or 14 weeks after randomization, whichever occurred first) and continued for an additional 12 weeks.
The coprimary effectiveness outcomes were Physician Global Assessment (PGA) dichotomized as clear/almost clear skin (score of ≤1) at the end of the intervention period and Dermatology Life Quality Index (DLQI) score of 5 or lower (no to small effect on quality of life) at week 12. 25 , 26 Patient-reported outcomes were captured via an app (Medable) using patients’ cell phones with automated text reminders. Patients were compensated $20 per survey. The primary safety outcome was the proportion of patients reporting treatment-emergent adverse events, such as the amount of persistent erythema (eg, sunburn), which were documented prior to each in-office phototherapy treatment by clinic staff or via the home phototherapy machine’s user interface. Patients were queried about any serious adverse events by the sites at the follow-up appointment (week 12) and could report serious adverse events at any point. Secondary outcomes are described in the eMethods in Supplement 2 . We used the product of body surface area (BSA) × PGA to approximate the psoriasis area and severity index, as the latter is not measured in clinical practice but is often used in efficacy trials. 27
Patients were randomized using block randomization, stratified on clinic and SPT. Data analysts were blinded to group assignment. Patients and clinicians were not blinded.
This study was powered to determine noninferiority of home-based phototherapy within SPT strata. We prespecified 2 primary effectiveness outcomes. Sample size was determined based on a 1-sided α level of 2.5%, a 50% response rate, and 80% power to establish noninferiority with a margin of 15% (determined by meta-analyses and stakeholder input) within each SPT stratum. 28 - 31 This yielded a sample size of 350 per stratum. We did not explicitly account for multiple comparisons since the patient- and physician-reported measures assess the same outcome and are highly correlated.
All analyses were performed using Stata, version 18.0 (StataCorp), by R.C.F and D.B.S. We hypothesized that effectiveness of home-based UV-B phototherapy would be noninferior to office-based phototherapy for both primary effectiveness outcomes and across all SPTs. Primary analyses were based on the intent-to-treat population of randomized individuals. Patients with missing PGA or DLQI data were classified as experiencing treatment failure (ie, nonresponse imputation that assumed a PGA score of >1 and/or DLQI >5). Home-based phototherapy was deemed noninferior to office-based phototherapy if the lower bound of the SPT-adjusted 2-sided 95% CI for the response difference was greater than the prespecified noninferiority margin of 15% (detailed in the eMethods in Supplement 2 ). Given the potential for heterogeneity of treatment effect, separate analyses were planned a priori for each SPT. Secondary outcomes and exploratory analyses were analyzed and reported using response differences with 95% CIs and P values that were not adjusted for multiple comparisons and should be interpreted as exploratory and hypothesis generating. A 2-sided P < .05 was considered statistically significant for secondary outcomes. Binary and continuous outcomes were analyzed using logistic and linear regression, respectively, adjusted for SPT.
Dermatology practitioners determined that 1174 patients were appropriate for phototherapy at home or in the office, of whom 783 patients agreed to participate ( Figure ). The most common reasons for nonparticipation were not wanting to participate (n = 93); not being able to do office-based phototherapy due to inconvenience, co-payments, or lack of insurance coverage (n = 60); and not being able to do home-based phototherapy due to not having adequate space or concerns about operating the machine (n = 54). Baseline characteristics were similar in both groups ( Table 1 ). The mean (SD) age among patients was 48.0 (15.5) years; 376 (48%) were female; and 350 (44.7%) had SPT I/II, 350 (44.7%) had SPT III/IV, and 83 (10.6%) had SPT V/VI. Due to recruitment challenges, which coincided with the COVID-19 pandemic, enrollment among those with SPT V/VI was halted when enrollment was completed in the other strata. Patients lived a median (IQR) of 20 (9-40) miles from the dermatology office, and their co-payment for office-based phototherapy was a mean (SD) of $17.50 ($30.40) per treatment. Patients randomized to home-based phototherapy started treatment on average 8 days later than those randomized to in-office phototherapy. The most common comorbidities were cardiometabolic disease among 454 patients (58.0%), psoriatic arthritis among 133 (17.0%), and mood disorder or anxiety among 112 (14.3%). Patients had psoriasis for a mean (SD) of 15.8 (14.8) years, 312 (39.9%) previously received biologic or nonbiologic systemic therapy (93 patients [11.9%] were currently using these treatments), and 337 (43.0%) had previously been treated with phototherapy. Patients had moderate to severe disease (mean [SD] PGA of 2.7 [0.8] and BSA of 12.5% [15.7%]), with a large effect on HRQOL (mean [SD] DLQI of 12.2 [7.2]). 26
More patients achieved clear/almost clear skin or no to small effect on HRQOL in the home group (129 of 393 [32.8%] and 206 of 393 [52.4%], respectively) compared to the office group (100 of 390 [25.6%] and 131 of 390 [33.6%], respectively) ( Table 2 and eTable 1 in Supplement 2 ). Home-based phototherapy was noninferior to office-based phototherapy for both physician and patient-reported outcomes in the overall population and across all SPTs. Among those who achieved a DLQI score of 5 or lower at week 12, patients in both groups maintained this degree of HRQOL response for approximately 75 days of the possible 84 days of follow-up after phototherapy ended ( Table 3 ).
Patients undergoing home phototherapy were also more likely to achieve DLQI of 0/1 (no effect on HRQOL), a minimally clinically important difference in DLQI (difference, 12.0 [95% CI, 6.5-17.4] percentage points [pp]; P < .001), and a 75% and 90% reduction in BSA × PGA (difference, 11.5 [95% CI, 5.2-17.9] pp; P < .001; and 8.2 [95% CI, 2.5-13.9] pp; P = .005, respectively; Table 3 ). Patients undergoing home phototherapy used topical treatments less frequently (0.8 [95% CI, 0.4-1.3] days fewer per week; P = .001) and were less likely to start oral or biologic treatments during the 12-week treatment period (difference, −2.6 [95% CI, −5.9 to 0.7] pp; P = .12). Patients undergoing home phototherapy spent slightly less time on treatments compared to the office group (−3.2 [95% CI, −1.0 to 0.6] minutes per treatment; P = .09). However, patients undergoing treatment in an office spent a mean (SD) of 50.3 (46.7) minutes traveling to and from each treatment with patient-reported travel costs of approximately $20 per treatment (eg, an estimated $720 for a 12-week treatment course).
Compared to patients treated in office, patients assigned to home-based phototherapy were more likely to have a starting dose consistent with current guidelines, received a mean (SD) of 8.9 (0.9) more treatments, were 3.2 times more likely to receive at least 24 treatments (ie, on average at least 2 treatments a week, which is a marker of good adherence), 15 had a higher cumulative dose of narrowband UV-B, and had a higher rate of persistent erythema per treatment ( Table 4 ). In 35 of 56 treatments (62.5%) associated with persistent erythema in which a coincident DLQI score was obtained, patients reported “no” or only “a little itchy, sore, painful, or stinging skin.” Phototherapy was well tolerated by both groups, with no treatment discontinuations due to phototherapy adverse effects. There was a low rate of serious adverse events in the office-based group (4 events in 4 patients [1.0%]: breast cancer, osteosarcoma, chest pain, and infected wounds) and in the home-based group (5 events in 3 patients [0.8%]: substance misuse, neuropathy/mild malnutrition, and COVID-19/hypertension resulting in death), none of which were deemed treatment related.
Sensitivity analyses (eFigures 2-4 and eTable 2 in Supplement 2 ) evaluating varying approaches to missing data, evaluating varying adherence to treatment, evaluating center effects, and restricting to patients with no prior phototherapy experience yielded similar results to the primary analysis. However, statistical significance for noninferiority of PGA of clear/almost clear was not demonstrated in those who received at least 24 treatments due to very few patients assigned to office-based treatment achieving this degree of adherence (eTable 2 in Supplement 2 ).
The LITE study provides compelling evidence that home-based phototherapy is noninferior to office-based phototherapy for the treatment of plaque and guttate psoriasis across both physician- and patient-reported end points. Importantly, we evaluated a priori for heterogeneity of treatment effect, as the outcomes could be affected by patients with fair skin not tolerating home-based treatment as well (given less ability to fine-tune dosing) and patients with darker skin having poorer response (due to home machines having lower output and, thus, longer treatment times) and found strong evidence of noninferiority across all SPTs. Indeed, the benefits of home-based treatment relative to office-based treatment were strongest in patients with SPT V/VI, particularly for physician-reported measures, resulting in robust conclusions in this group despite relatively lower enrollment. These results extend a smaller pragmatic trial of home- vs office-based phototherapy for psoriasis conducted in the Netherlands prior to the modern biologic era, which also demonstrated noninferiority. 32
The LITE study entry criteria reflected routine dermatology clinical practice in the US. The patient population was more balanced for sex and more diverse than is typical of psoriasis efficacy trials of systemic agents. 33 The patient population had long-standing, objectively, and subjectively moderate to severe disease and a high prevalence of prior oral and biologic treatment, and 11.9% of patients were currently taking systemic psoriasis treatments, suggesting that this was a population with recalcitrant psoriatic disease. Nevertheless, clinical responses in the overall population were favorable, and among those who were adherent to phototherapy, about 50% achieved clear or almost clear skin, which is a high bar for effectiveness. 34 Collectively, these findings demonstrate the continued importance of phototherapy despite recent therapeutic advances.
LITE was designed as a noninferiority study, but the results suggest that patients achieved better outcomes when randomized to home-based phototherapy compared to office-based treatment. These observed differences are likely attributable to the substantial barriers patients receiving office-based phototherapy encounter, including both direct and indirect costs and inconvenience, which limit adherence. Some of these barriers can be addressed through policy changes (eg, eliminating co-payments for office phototherapy). Others can be addressed by making home-based phototherapy more accessible to patients, given the limited geographical availability of office-based phototherapy. The present results support considering home-based phototherapy as a first-line treatment option for psoriasis, including for patients who have never received office-based phototherapy. Therefore, insurers should not require a successful trial of office-based phototherapy as a step prior to covering home-based phototherapy. Indeed, some large integrated networks have made home-based phototherapy widely available, reducing use of more expensive systemic agents, which is consistent with the present results. 35 , 36
To our knowledge, LITE is the largest and most diverse study conducted of narrowband UV-B phototherapy for psoriasis to date. 37 A notable strength of the LITE study is that it was pragmatic by being embedded in routine, everyday care. Therefore, the results are likely generalizable to the broader population of patients with psoriasis. However, it is likely that we underestimated the direct and indirect costs of office-based phototherapy to patients, as individuals who had high co-payments or a long distance to travel for treatment frequently declined participation. Those assigned to home-based phototherapy received the device at no cost due to the aforementioned insurance barriers, which would have made it infeasible to conduct this research. In 2024, Medicare covered the device we studied at $6040.88, with direct cost to patients varying based on their insurance plan. 38 Those randomized to home-based phototherapy initiated treatment within approximately 20 days, demonstrating the feasibility of starting treatment quickly when prior authorization barriers are removed. As expected in a pragmatic design, there were missing outcome data, as patients may not have returned to the office for follow-up. This phenomenon is also commonly seen with biologic therapies in everyday settings in which patients often do not initiate prescribed treatment and/or do not attend follow-up appointments. 39 , 40 Nevertheless, sensitivity analyses using different approaches to missing data were consistent with the primary analysis. Based on the tipping point analysis, it is unlikely that missing outcome data meaningfully affected the conclusions. We did not adjust for multiple comparisons; however, most differences were associated with very small P values, which suggests that they would still reach statistical significance even under conservative multiple testing adjustment.
Both home- and office-based phototherapy were well tolerated, with no discontinuations due to adverse effects; however, home-based treatment was associated with a higher frequency of persistent erythema. Episodes of persistent erythema are expected based on phototherapy dosing guidelines and did not appear to be clinically important; however, patients and/or clinicians who are concerned about this adverse effect could adjust the protocol to be less erythrogenic than the standard guidelines. 15 As expected, there was no evidence of misuse of home-based phototherapy based on evaluation of dosing data captured from the machines. Importantly, patients receiving phototherapy at home were more likely to start treatment at the recommended starting dose than those receiving office-based treatment, particularly in patients with darker skin. Therefore, the better observed responses for home-based phototherapy may be related to better adherence to treatment guidelines for both dosing and treatment frequency. LITE was designed to reflect routine care and, therefore, we did not collect physician-reported data on duration of treatment response; however, patient-reported data suggested strong persistence of benefits in HRQOL up to 12 weeks posttreatment discontinuation. Prior research suggests that patients maintain good objective control of psoriasis when no longer receiving phototherapy for about 6 to 12 months or longer and that maintenance treatment (ie, 1 phototherapy treatment per week) can further extend disease remission. 41 - 44 Hypothetically, long-term treatment with narrowband UV-B phototherapy could increase the risk of basal cell, squamous cell, and melanoma skin cancer in patients with fair skin; however, existing studies have not observed an increased risk for these skin cancers in those treated with this modality and followed for many years. 17 , 18
In this randomized clinical trial, home-based phototherapy was noninferior to office-based phototherapy across all SPTs and for both patient- and physician-reported outcomes. Home-based phototherapy was substantially less burdensome to patients and had better treatment adherence than office-based phototherapy. Phototherapy delivered at home or in the office resulted in excellent outcomes for patients. Efforts should be made to make these safe, effective, and relatively inexpensive treatment options more available to patients in the modern era of psoriasis therapeutics.
Accepted for Publication: August 2, 2024.
Published Online: September 25, 2024. doi:10.1001/jamadermatol.2024.3897
Corresponding Author: Joel M. Gelfand, MD, Department of Dermatology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104 ( [email protected] ).
Author Contributions: Dr Gelfand had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Gelfand, Feldman, Kalb, Krell, Bridges, Fielding, Nehal, Schaecher, Howard, Báez, Papadopoulos, Hubbard, Shin, Callis Duffin.
Acquisition, analysis, or interpretation of data: Gelfand, Armstrong, Lim, Feldman, Johnson, Claiborne, Kalb, Jakus, Mangold, Flowers, Bhutani, Durkin, Bagel, Fretzin, Sheehan, Krell, Reeder, Kaffenberger, Kartono, Takeshita, Fielding, Schaecher, Howard, Eakin, Báez, Bishop, Fitzsimmons, Papadopoulos, Song, Linn, Hubbard, Shin, Callis Duffin.
Drafting of the manuscript: Gelfand, Lim, Mangold, Fielding, Schaecher, Fitzsimmons, Papadopoulos, Song, Shin, Callis Duffin.
Critical review of the manuscript for important intellectual content: Armstrong, Lim, Feldman, Johnson, Claiborne, Kalb, Jakus, Mangold, Flowers, Bhutani, Durkin, Bagel, Fretzin, Sheehan, Krell, Reeder, Kaffenberger, Kartono, Takeshita, Bridges, Nehal, Schaecher, Howard, Eakin, Báez, Bishop, Fitzsimmons, Papadopoulos, Song, Linn, Hubbard, Shin, Callis Duffin.
Statistical analysis: Gelfand, Bagel, Fitzsimmons, Papadopoulos, Song, Hubbard, Shin.
Obtained funding: Gelfand, Papadopoulos, Callis Duffin.
Administrative, technical, or material support: Gelfand, Armstrong, Lim, Johnson, Claiborne, Kalb, Mangold, Bhutani, Durkin, Kartono, Howard, Eakin, Báez, Bishop, Papadopoulos, Song.
Supervision: Gelfand, Lim, Durkin, Bagel, Fretzin, Sheehan, Bridges, Nehal, Báez, Papadopoulos, Linn, Shin.
Conflict of Interest Disclosures: Dr Gelfand reported receiving honoraria for serving as a consultant for AbbVie, Artax, BMS, Boehringer Ingelheim, Celldex, FIDE (which is sponsored by multiple pharmaceutical companies), GSK, Inmagene, Lilly, Leo Pharma, Moonlake, Janssen Biologics, Novartis, Oruka, UCB, Neuroderm, and Veolia North America; receiving research grants to the trustees of the University of Pennsylvania from Amgen, BMS, and Pfizer; receiving payment for continuing medical education work related to psoriasis that was supported indirectly by pharmaceutical sponsors; coholding a patent for resiquimod for treatment of cutaneous T-cell lymphoma; serving as Deputy Editor for the Journal of Investigative Dermatology and receiving honoraria from the Society for Investigative Dermatology; serving as Chief Medical Editor for Healio Dermatology and receiving honoraria; and serving as a member of the board of directors for the International Psoriasis Council and the Medical Dermatology Society, receiving no honoraria. Dr Armstrong reported receiving grants from AbbVie, Aslan, BMS, Dermavant Sciences, Dermira, Lilly, Galderma, Incyte, Janssen; Leo Pharma, Meiji Seika Pharma, Modernizing Medicine, Nimbus Therapeutics, Novartis, Ortho Dermatologics, Pfizer, Sanofi/Genzyme, UCB, and Ventyx Biosciences; receiving personal fees from AbbVie, Aslan, Almirall, Amgen, Arcutis, Beiersdorf, BMS, Dermavant, EPI Health, Lilly, Janssen, Leo Pharma, Mindera, Nimbus, Organon, Sanofi, Sun Pharma, Takeda, Ventyx Biosciences, Galderma, Incyte, Regeneron, and UCB; receiving other support from Boehringer Ingelheim; and serving on the Parexel Data Safety Monitoring Board outside the submitted work. Dr Lim reported grants from Incyte, La Roche-Posay, and Pfizer as well as personal fees from ISDIN, Beiersdorf, Ferndale, L’Oréal, Lilly, Zerigo, Skinosive, La Roche-Posay, Cantabria Labs, Pierre Fabre, NAOS, Uriage, and Pfizer outside the submitted work. Dr Feldman reported receiving research, speaking, and/or consulting support from Lilly, GlaxoSmithKline/Stiefel, AbbVie, Janssen, Alvotech, vTv Therapeutics, Bristol Myers Squibb, Samsung, Pfizer, Boehringer Ingelheim, Amgen, Dermavant, Arcutis, Novartis, Novan, UCB, Helsinn, Sun Pharma, Almirall, Galderma, Leo Pharma, Mylan, Celgene, Ortho Dermatology, Menlo, Merck, Qurient, Forte, Arena, Biocon, Accordant, Argenx, Sanofi, Regeneron, the National Biological Corporation, Caremark, Teladoc, BMS, Ono, Micreos, Eurofins, Informa, UpToDate, Verrica, and the National Psoriasis Foundation; he is also founder and part owner of Causa Research and holds stock in Sensal Health. Dr Claiborne reported personal fees from Sanofi, Regeneron, Arcutis, and UCB outside the submitted work. Dr Kalb reported grants from the University of Pennsylvania during the conduct of the study and grants from AbbVie, CorEvitas, Lilly, Janssen, PPD, and UCB outside the submitted work. Dr Jakus reported grants from SUNY Downstate Health Sciences University during the conduct of the study and grants from Arcutis, Dermavant, Amgen, and Incyte outside the submitted work. Dr Mangold reported personal fees from Argenyx, Boehringer Ingelheim, Bristol Myers Squibb, Lilly, Incyte, Janssen, Kyowa, Phlecs, Regeneron, Soligenix, and UCB, as well as grants from Lilly, Argenyx, Bristol Myers Squibb, Incyte, Pfizer, Regeneron, Soligenix, AbbVie, Priovant, Novartis, Palvella, and Horizon Therapeutics outside the submitted work. Dr Flowers reported other support from Acelyrin, AbbVie, Clinuvel, Sun Pharmaceutical, and Regeneron/Sanofi, as well as personal fees from Argenyx, BMS, and Janssen outside the submitted work. Dr Fretzin reported serving as a speaker and investigator for AbbVie, Amgen, Lilly, Janssen, Dermavant, and Incyte. Dr Sheehan reported grants from the National Psoriasis Foundation during the conduct of the study. Dr Krell reported support from AbbVie, Bristol Myers Squibb, UCB, Sun Pharmaceutical, Janssen Biotech, Amgen, and Lilly outside the submitted work. Dr Kaffenberger reported grants from AbbVie, Amgen, Celgene, Corrona, Lilly, Incyte, Janssen, Novartis, Pfizer, Regeneron, and UCB outside the submitted work. Dr Takeshita reported grants from Bristol Myers Squibb and Pfizer and personal fees from Incyte outside the submitted work. Dr Bridges reported personal fees from Johnson & Johnson/Janssen, Health Union, Bristol Myers Squibb, IDEOM, Wego, IGMCARE, AbbVie, the Global Healthy Living Foundation, and RVO outside the submitted work, as well as volunteering with the National Psoriasis Foundation on various projects. Dr Linn reported personal fees from JAMA Network Open and Correlation One outside the submitted work. Dr Callis Duffin reported personal fees from Amgen, AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, Lilly, Janssen, Novartis, UCB, and CorEvitas, as well as grants from Boehringer Ingelheim, Pfizer, Bristol Myers Squibb, Lilly, UCB, and CorEvitas outside the submitted work. No other disclosures were reported.
Funding/Support: The Patient-Centered Outcomes Research Institute funded the study. Daavlin provided home phototherapy machines and shipped the machines to and from patients’ residences at no cost. At the discretion of the prescriber, Daavlin provided education to patients on how to use the home devices per standard of care.
Role of the Funder/Sponsor: The Patient-Centered Outcomes Research Institute and Daavlin had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Meeting Presentation: This study was presented at the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis annual meeting adjacent to the European Academy of Dermatology and Venereology Congress 2024; September 25, 2024; Amsterdam, the Netherlands.
Data Sharing Statement: See Supplement 3 .
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IMAGES
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COMMENTS
These providers are called "non-participating." If your doctor, provider, or supplier doesn't accept assignment: You might have to pay the full amount at the time of service. They should submit a claim to Medicare for any Medicare-covered services they give you, and they can't charge you for submitting a claim.
The second reimbursement method a physician/supplier has is choosing to not accept assignment of benefits. Under this method, a non-participating provider is the only provider that can file a claim as non-assigned. When the provider does not accept assignment, the Medicare payment will be made directly to the beneficiary.
Non-assigned is the method of reimbursement a physician/supplier has when choosing not to accept assignment of benefits. Under this method, a non-participating provider is the only provider that can file a claim as non-assigned. When the provider does not accept assignment, the Medicare payment will be made directly to the beneficiary.
Medicare assignment is a fee schedule agreement between the federal government's Medicare program and a doctor or facility. When Medicare assignment is accepted, it means your doctor agrees to the payment terms of Medicare. Doctors that accept Medicare assignment fall under one of three designations: a participating doctor, a non ...
Medicare assignment is an agreement by your doctor or other healthcare providers to accept the Medicare-approved amount as the full cost for a covered service. Providers who "accept assignment" bill Medicare directly for Part B-covered services and cannot charge you more than the applicable deductible and coinsurance.
Published September 02, 2022. /Updated February 10, 2024. Because Medicare decides how much to pay providers for covered services, if the provider agrees to the Medicare-approved amount, even if it is less than they usually charge, they're accepting assignment. A doctor who accepts assignment agrees to charge you no more than the amount ...
Non-participating providers accept Medicare but do not agree to take assignment in all cases (they may on a case-by-case basis). This means that while non-participating providers have signed up to accept Medicare insurance, they do not accept Medicare's approved amount for health care services as full payment.
Summary: Medicare Assignment is an agreement between healthcare providers and Medicare, where providers accept the Medicare-approved amount as full payment, preventing them from charging beneficiaries extra. This benefits Medicare beneficiaries by controlling their costs and ensuring they only pay deductibles and copayments.
or not to accept assignment. When they accept assignment, Medicare makes the payment directly to the physician and collects the 20 percent coinsurance from the patient, but the physician cannot collect the full limiting charge amount. For unassigned claims, Medicare reimburses the patient and the physician collects the entire limiting charge
1. Participating providers, or those who accept Medicare assignment. These providers have an agreement with Medicare to accept the Medicare-approved amount as full payment for their services. You don't have to pay anything other than a copay or coinsurance (depending on your plan) at the time of your visit.
Assignment is a term used to describe the agreement between a healthcare provider and Medicare to accept the Assignment is a term used to describe the agreement between a healthcare provider and Medicare to accept the.; If a beneficiary is enrolled in Medicare, and they visit a provider who accepts assignment, they may be responsible for paying a copayment or coinsurance for certain services.
Provider does not accept Medicare assignment: The provider will accept the Medicare-approved amount for services in certain cases. This is also known as "non-participating" with Medicare. The member may have to pay for services up front and be reimbursed up to 115% Medicare reimbursement rates for covered services.
Participating vs. Non-Participating Medicare "participation" means you agree to accept claims assignment for all Medicare-covered services to your patients. By accepting assignment, you agree to accept Medicare-allowed amounts as payment in full. You may not collect more from the patient than the Medicare deductible and coinsurance or ...
See Plans Online. Call 1-855-792-0088. Mon - Fri, 8 a.m. - 6 p.m. CT — TTY 711. When a doctor accepts Medicare assignment, they agree to accept whatever amount Medicare will pay for the service as paid in full. Find out more.
If the beneficiary chooses to use a non-contracted supplier and waive their Medicare benefits, the item would be a cash transaction. In such a case, the supplier should make sure to use an Advance Beneficiary Notice of Non-Coverage (ABN). Myths About Assignment and Non-Assignment. A participating supplier gets reimbursed at a higher rate. False.
Medicare assignment is a fee schedule that is agreed upon between the federal government and your doctor. Here is how it works and what you need to know.
1. Participating providers, or those who accept Medicare assignment. These providers have an agreement with Medicare to accept the Medicare-approved amount as full payment for their services. You don't have to pay anything other than a copay or coinsurance (depending on your plan) at the time of your visit.
Medicare sets a fixed cost to pay for every benefit they cover. This amount is called Medicare assignment. You have the largest healthcare provider network with over 800,000 providers nationwide on Original Medicare. You can see any doctor nationwide that accepts Medicare. Understanding the differences between your cost and the difference ...
According to the Medicare website: Assignment means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services. This means that for Medicare to cover the entire cost of a covered service, you'll need to go to a service provider who accepts assignment.
Understanding Medicare assignment is crucial to help keep your medical expenses low. Learn about who accepts it, how it affects your costs, and more.
What is a non-participating provider under Medicare? A non-participating provider has agreed to accept Medicare insurance but not accept assignment. Consequently, non-participating providers may charge up to 15% above the Medicare approved amount for the Medicare-covered service. This extra payment is called the limiting charge.
Generally, a provider or supplier will be assigned to the Medicare Administrative Contractor (MAC) that covers the state where the provider or supplier is located. The Center for Medicare & Medicaid Services' (CMS) has defined the following approach for assigning providers, physicians, and suppliers to MACs. return to top.
Assignment of benefits is not authorization to submit claims. It is important to note that the beneficiary signature requirements for submission of claims are separate and distinct from assignment of benefits requirements except where the beneficiary died before signing the request for payment for a service furnished by a supplier and the supplier accepts assignment for that service.
In 2024, Medicare covered the device we studied at $6040.88, with direct cost to patients varying based on their insurance plan. 38 Those randomized to home-based phototherapy initiated treatment within approximately 20 days, demonstrating the feasibility of starting treatment quickly when prior authorization barriers are removed. As expected ...