To PAR or Not to PAR?

The Essential Question for Most Medical Providers

By Staff Reporters

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Ever since 1992, doctors are paid per resource-based relative value unit (RBRVU) and according to the lesser of the actual billed charges or the fee schedule amount. But, there are two types of providers. 

  • Those who accept Medicare assignment only bill the patient for the co-payment, which is usually 20%. 
  • Those who do not accept Medicare assignment are offered a lower fee schedule of 95% of the approved schedule, which is a 115% maximum fee limit of the approved schedule.

So, how does this work in real life?


A participating physician’s approved fee schedule charge of $100 would yield $80 from Medicare and $20 from the patient.

A non-participating (Non-Par) doctor with charges of $200, and with an approved fee schedule of $100, would yield: $109.25 = (.95 X $100) X 1.15 entirely from the patient. If the Non-Par doctor selects payment type on a case-by-case basis, Medicare will pay its portion of the bill directly to the physician, but the doctor must accept the Non-Par fee schedule.


Continuing our example yields: (.8 X $95) plus the patient’s co-payment of (.2 X $95), OR $76 plus $19 = $95.00.


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4 Responses

  1. Rethinking Private Par, Too?

    As many physicians have concluded, out-of-network insurance benefits pay better than the prevailing in-network rates. Some practices have opted out, terminating their participation status with major insurance carriers.

    The practices that have remained in-network, sitting on the sidelines watching this unfold, are realizing that they may be placed at a disadvantage for remaining a network participant.



  2. Bipartisan Senate duo wants Medicare to make payments to doctors public

    Sens. Ron Wyden (D-Ore.) and Chuck Grassley (R-Iowa) are collaborating on legislation to require the federal government to make public how much it pays doctors who participate in Medicare.

    Payments to doctors and other individual providers in the Medicare claims database has been off-limits to the public since the 1970s, when the Florida Medical Association and the American Medical Association sued to keep it secret. The issue has resurfaced in recent months after The Wall Street Journal and the Center for Public Integrity sued the Department of Health and Human Services to get the information.

    Those pushing for access to the database believe it could reveal major fraud that costs taxpayers greatly.



  3. Entitlement Spending Next on Agenda
    [According to Eric Cantor]

    As House leaders prepare to vote on a short-term spending bill to avert a government shutdown, the No. 2 Republican in that chamber told hospital executives that the House will next address entitlement spending.

    “It will likely be the first time you see a House have a prescription for Social Security, Medicare, and Medicaid,” House Majority Leader Eric Cantor (R-VA) said to attendees of the recent Federation of American Hospitals’ annual public policy conference and business exposition in Washington.

    The so-called continuing resolution for the remainder of 2011 that is the center of debate on Capitol Hill this week deals with discretionary spending, but not entitlement programs. House and Senate Republicans recently chided President Barack Obama for not tackling entitlement reform in his budget, which he released Feb. 14th. The House will release its budget this spring, and Cantor’s comments suggest entitlement reform will be a part of that financial framework.

    Source: Jessica Zigmond, Modern Healthcare [3/1/11]


  4. Try Direct Care Medicine Instead

    Physicians running direct primary care practices say there’s no reason for health insurers to be involved in primary care. Most people’s needs for such care are predictable.

    And, the monthly fees mean doctors can maintain much smaller patient populations, spend less time billing payers and more time providing care, and communicate with patients more by phone and email.

    Dr. Blue


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