Medicare Billing Problems | Non-participating provider

I got a call this evening from an NP friend of mine who opened her practice in November 2006. She’s been dealing with doing electronic billing with Medicare. She tells me that after months of working with them, doing test runs, etc…they were all ready to do. Now mind you, these test runs were done with Medicare…everyone said it’s a go.

So they upload billing going back SEVEN months. And guess what? Medicare kicked them all back and said she could not bill.

Apparently, in her prior job, they opted out of Medicare. Guess what? That opt out form is apparently good for two years. It follows you where-ever you go. Medicare is now telling her she cannot bill for ANY visits until after July 1, 2007. It is possible this is correct?

I gave her the number for the local regional office where hopefully she can talk with someone who has a bit more knowledge than those answering the call center phones. Any other ideas?

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  1. I dread the issues with Medicare. I don’t even have a clue where to start. I will be working in an office with a physician and I hope to figure it all out soon. I put a link to your site on my site The Nurse Practitioner’s Place.

  2. I read in detail about this on the noridian website. It actually sounded initially if you were a non participating Medicare provider, you still collect, just not the full amount which is an extra small percentage, and as a participating provider, you agree to the exact medicare reimbursement as your full payment. I did hear two years, but again it was unclear as to which benefited the provider more. I never heard that the non participating provider could not bill Medicare at all,.. I spoke with a person as well. This does need a bit of clarification. I am still applying for my Medicare credentialing, so I will get back on this. Carla

  3. It is possible. My concern is that she didn’t check to assure that she was credentialed with Medicare before submitting those claims. She will need to reapply to become a participating provider for both herself and her practice. AND she will need to notify Medicare that she is no longer working for the previous group.

    When providers are credentialed there is some fine print that places the responsibility squarely upon our shoulders of notifying Medicare (and other products) when we terminate employment/practice. Medicare has a form with which to do this.

    Some of this information can be found here:

  4. Our facility is based on Substance Abuse we do not participate with medicare or registered with medicare and we are a for profit org. I have a dilemma in trying to obtain some type of denial so the 2ndary supplemental insurance can pay, our clients tend not to disclose to us that they have medicare as a primary insurance so when we bill out to the insurance they need some type of non par ltr or a denial does anyone know how to obtain this? I’ve tried calling several telephone#’s for California Medicare but I always end up with the wrong dept or an automated service that has no option for a representative, so anyone with experience with advice on this matter appreciated.

  5. Thus is in responce to Arlene Pena. You can bill Medicare using the patients’ ssn ending with an ‘A” as most medicare #.’s do. As of September the medicare claims processing is contracted by Palmetto GBA in Florida. You can get their billing address by visiting their support website
    To the others commentitng about medicare billing, I havre experienced the worst nightmare immaginable by any biller. For over two years our office has inquired about errors that are preventing reimbursement and each time we were given a different reason, we corrected these, rebilled many accounts with repeated wrong excuses. LAST MONTH WE WERE TOLD THAT THE PROVIDER IDENTITY .Management office incorrecty updated us with one number wrong on the provider tax id # on MAY 3, 2005 They owe us over $250,000.00 and have still not paid us for these back claims to date-READY TO SCREAM!!!…

  6. I have been trying to get our office hooked back up to medicare part b for three months now, and it is a nightmare…….I was told to file paper claims and then to do electronic claims and still we are doing it wrong. Then I was told just fill out the forms and send them in now I have done this 2 times and I called today to be told that we don’t qualify because the counselors are not doctors, I am ready to scream. Now I am told to get a paper stating that medicare won’t pay for us ,so medicaid will?

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    Medicare can be an absolute nightmare. Usually, I have found that if Medicare does not pay, neither will DSHS.
    Do you have a biller that is helping you with this? If not, I’ll recommend someone that many of the members of NPBO are using. She has been able to help with getting all the Medicare craziness straightened out so you can bill.


  8. I have been trying for a month to get information on how to be signed up with medicare so that I can bill medicare for shoes that I have made for people. I am a Small Business Called L.G.O.Custom Soles and I make custom molded Orthopedic and diabetic shoes. I have sent out 3 letters to different places with no responce. All I want is to make the shoes, and be able to file the information to get paid. I have looked on the web sites for medicare and I can’t find anything pertaining to what I make. How do I go about getting connected to medicare.Please help!


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    Hi Linda,

    You are not alone. Medicare can frustrate the best of us!

    I spoke with Mylikia Ross of and here is the information she gave:

    Go to

    You will need to enroll with the National Supplier Clearinghouse to become a Durable Medical Equipment (DME) supplier. The link above is an overview of the process.

    Let us know if this helps.

    Barbara C. Phillips, NP
    Facebook NP Group:

  10. I hear “Medicare is very frustrating” everyday. I work for a company that assists with Medicare claims. All of our clients are pleased when they find out about our services. I believe we can help a few of you. We enhance the effectiveness of the claims process from start to finish. Our basic tool (MVP live) gains patient eligibility information from the FISS system within 90 seconds. After the information is aquired, the process of the claim is tracked by our company until the payment hits the floor. We report secondary payer information, discrepancies, and status changes, as well as other key information that a provider needs for payment. If you would like more information, you may email me at

  11. Hi
    I work for non-profit organization and we provide mental health services. We served clients had Medicare and Medicaid but we are not Medicare provider. I want to submit paper claim but seem likely I cannot find the Medicare claims address. I went online but no luck. Does any one have the address and telephone number for Claims Department only and please forward it to me.


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