PAR vs. Non-PAR Medicare Providers
The distinction between Participating (PAR) and Non-Participating (Non-PAR) Medicare providers remains critical for financial planning and patient care. Below is an updated overview incorporating 2025 Medicare changes from the CMS Final Rule and other recent updates:
1. Key Differences Between PAR and Non-PAR Providers
| Aspect | PAR Providers | Non-PAR Providers |
|---|---|---|
| Reimbursement Rates | Accept Medicare-approved rates as full payment (5% higher than Non-PAR rates) 2. | Can charge up to 115% of the Non-PAR fee schedule (limiting charge) 211. |
| Patient Costs | Patients pay only deductibles/coinsurance; Medicare covers 80% directly 2. | Patients pay upfront; Medicare reimburses 80% of the Non-PAR rate, leaving balance due 11. |
| Administrative Burden | Higher due to compliance with Medicare billing rules 11. | Lower, as providers avoid Medicare’s administrative requirements 11. |
| Flexibility | Limited to Medicare’s fee schedules. | Can set custom rates but face challenges collecting balances 11. |
2025 Updates:
- Reimbursement Cuts: The 2025 PFS conversion factor drops to $32.36 (2.83% reduction from 2024) 1812. PAR providers face lower payments, while Non-PAR providers’ limiting charges adjust accordingly.
- Legislative Fix: A proposed Medicare Patient Access Act (H.R. 10073) aims to offset cuts, but its passage is uncertain 18.
2. Behavioral Health and Telehealth Adjustments
- Telehealth Restrictions: Geographic/site limitations return (e.g., patients’ homes no longer valid for most services), except for behavioral health 18.
- PAR providers must adapt to rural/clinical originating sites.
- Non-PAR providers lose flexibility for non-behavioral telehealth in urban areas.
- New Behavioral Health Codes: Codes like G0560 (safety planning) and G0544 (post-discharge follow-up) allow billing for telehealth interventions 712.
3. Caregiver Training and New Codes
- Caregiver Training (G0539–G0543): Reimbursable for PAR providers; Non-PAR must ensure charges align with Medicare’s Non-PAR rates 17.
- Advanced Primary Care Management (APCM): Tiered codes (G0556–G0558) replace older care management codes, simplifying billing for chronic care 8.
4. Medicare Advantage (Part C) Changes
- Expanded Provider Networks: Medicare Advantage now covers services from marriage/family therapists (MFTs) and mental health counselors (MHCs) 12.
- PAR providers in these specialties may see increased patient volume.
- Non-PAR providers not contracted with Medicare Advantage risk losing beneficiaries.
5. Strategic Considerations for 2025
- PAR Providers:
- Leverage behavioral health telehealth exceptions to maintain access 18.
- Adopt APCM codes to streamline chronic care billing 8.
- Non-PAR Providers:
- Re-evaluate pricing strategies to account for the 2025 fee schedule cuts.
- Consider contracting with Medicare Advantage plans to offset revenue loss 12.
- All Providers:
- Monitor legislative updates (e.g., H.R. 10073) to mitigate reimbursement cuts 1.
- Train staff on new codes (e.g., caregiver training, safety planning) 712.
Conclusion
The 2025 Medicare changes intensify financial pressures but offer opportunities through new codes and telehealth flexibilities. PAR providers benefit from predictable payments and expanded behavioral health billing, while Non-PAR providers retain pricing autonomy but face collection challenges.
Strategic adaptation—such as adopting new codes and renegotiating contracts—is essential for sustainability. For detailed guidance, review the 2025 CMS Final Rule
FAQs: PAR vs. Non-PAR Medicare Providers (2025 Updates)
1. PAR providers accept Medicare-approved rates as full payment (5% higher than Non-PAR rates) and cannot balance-bill patients.
2. Non-PAR providers can charge up to 115% of the Non-PAR fee schedule (the “limiting charge”) but must collect payment upfront and risk delayed Medicare reimbursements.
1. The 2025 PFS conversion factor drops to $32.36 (2.83% cut from 2024).
2. PAR providers receive lower payments but retain predictable Medicare revenue.
3. Non-PAR providers must adjust their limiting charges to reflect the reduced Non-PAR fee schedule.
1. Yes, but with restrictions: Geographic/site limitations return (e.g., urban patients must visit clinical sites), except for behavioral health services (e.g., safety planning, follow-ups).
2. Non-PAR providers can bill telehealth for behavioral health from any location.
Key codes include:
1. G0560: Safety planning for suicidal patients (telehealth eligible).
2. G0544: Post-discharge follow-up for behavioral health.
3. G0539–G0543: Caregiver training (reimbursable for PAR providers).
4. APCM codes (G0556–G0558): Simplify chronic care management billing.
1. Medicare Advantage now covers marriage/family therapists (MFTs) and mental health counselors (MHCs).
2. PAR providers: May see higher patient volume in these specialties.
3. Non-PAR providers: Risk losing patients if not contracted with Medicare Advantage plans.
No. Enrollment decisions are binding for the entire calendar year (Jan 1–Dec 31).
1. PAR providers: Adopt APCM codes for streamlined chronic care billing.
2. Non-PAR providers: Negotiate contracts with Medicare Advantage plans or re-evaluate pricing strategies.
3. All providers: Monitor the Medicare Patient Access Act (H.R. 10073), which may reverse cuts if passed.
Yes. Behavioral health services (e.g., G0560, G0544) can be delivered to patients at home, regardless of location.
Charging above 115% of the Non-PAR rate violates Medicare rules and risks penalties or exclusion from Medicare.
