Making the Right Decisions Can Positively Affect Your Revenue Cycle
Can Chiropractors Opt Out of Medicare?
First, you must be aware that “opting out” and being non-par are not the same thing.
Opting out refers to a physician’s ability to not bill Medicare at all. CMS determines which provider types can opt-out. These providers must file a valid affidavit with Medicare. After this, the provider can enter into a private contract with a Medicare beneficiary.
Secondly, you must be aware that, under Medicare rules, chiropractors are not eligible to opt out of Medicare. If a chiropractor sees and treats a Medicare beneficiary, they must be enrolled in Medicare and follow Medicare’s guidelines.
Introduction
July 30, 2025, marked the 60th anniversary of President Lyndon Johnson signing into law the legislation creating Medicare. When it began, approximately 19 million Americans enrolled. Today, more than 68 million Americans – and more than 1.5 million Massachusetts residents – are covered by Medicare. With so many covered lives in our state, it is imperative that all offices understand proper Medicare billing and how the billing decisions you make affect your revenue cycle.
Each year, when Medicare releases the new Medicare Physician Fee Schedule (MPFS), the Mass Chiro office receives questions about the fee schedule and exactly what the designations found in the schedule mean. Providers need to plan ahead, weigh the advantages and disadvantages, and decide whether to participate for the following year. Changes can be made during the annual participation open enrollment period, typically mid-November through December 31.
This article outlines the differences between participating and non-participating in Medicare, assisting chiropractors in making this important decision.
Chiropractic and Medicare
Eligibility for Medicare requires U.S. citizenship and meeting one or more of the following:
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65 years of age or older
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Disability and receiving Social Security for at least two years
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End Stage Renal Disease (ESRD) or ALS
What Is “Opting Out” of Medicare?
Again, CHIROPRACTORS ARE NOT ELIGIBLE TO OPT OUT. Other provider types may, but chiropractors are always required to bill Medicare if treating a Medicare beneficiary.
The Advance Beneficiary Notice (ABN), or Medicare waiver, is NOT an “opt-out.” It is a written notice given to the patient before providing a service that may not be covered, letting them know they will be responsible for the cost if Medicare denies the claim.
If you have been seeing Medicare beneficiaries and not billing Medicare, you may be in violation of the Social Security Act [Section 1848(g)(4)].
Participating vs. Non-Participating
Participating (Par):
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Always accepts assignment
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Bills Medicare directly
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Receives Medicare-approved amount as full payment (patient pays deductible/coinsurance)
Non-Participating (Non-Par):
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May accept assignment on a case-by-case basis
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If not accepting assignment, may charge up to 15% above the Non-Par approved amount (Limiting Charge)
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Still must bill Medicare for covered services
Massachusetts Example Fee Schedule – CPT 98941
| Provider Type | Medicare-Approved Amount | Limiting Charge (115%) | Patient Coinsurance (20%) | Medicare Pays (Non-Par) | Patient Pays (Non-Par) |
|---|---|---|---|---|---|
| Participating (Par) | $38.71 | — | $7.74 | $31.00 | $7.74 |
| Non-Par (Accepts Assignment) | $38.71 | — | $7.74 | $31.00 | $7.74 |
| Non-Par (No Assign) | $38.71 | $44.52 | $7.74 | $31.00 | $13.55 |
Expanded Massachusetts Fee Schedule – CPT 98940–98942
| Provider Type | Medicare-Approved Amount | Limiting Charge (115%) | Patient Coinsurance (20%) | Medicare Pays (Non-Par) | Patient Pays (Non-Par) |
|---|---|---|---|---|---|
| Participating (Par) – CPT 98940 | $29.85 | — | $5.97 | $23.88 | $5.97 |
| Non-Par (Accepts Assignment) – CPT 98940 | $29.85 | — | $5.97 | $23.88 | $5.97 |
| Non-Par (No Assign) – CPT 98940 | $29.85 | $34.33 | $5.97 | $23.88 | $9.45 |
| Participating (Par) – CPT 98941 | $38.71 | — | $7.74 | $31.00 | $7.74 |
| Non-Par (Accepts Assignment) – CPT 98941 | $38.71 | — | $7.74 | $31.00 | $7.74 |
| Non-Par (No Assign) – CPT 98941 | $38.71 | $44.52 | $7.74 | $31.00 | $13.55 |
| Participating (Par) – CPT 98942 | $47.20 | — | $9.44 | $37.76 | $9.44 |
| Non-Par (Accepts Assignment) – CPT 98942 | $47.20 | — | $9.44 | $37.76 | $9.44 |
| Non-Par (No Assign) – CPT 98942 | $47.20 | $54.28 | $9.44 | $37.76 | $16.52 |
Key Takeaways
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Chiropractors cannot opt out of Medicare. All chiropractors treating Medicare beneficiaries must be enrolled and follow Medicare billing rules.
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Par vs. Non-Par affects payment flow, not provider eligibility. Participation status determines how and when you’re paid, and how much the patient owes.
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Par providers always accept Medicare’s approved amount as payment in full and receive payments directly from Medicare.
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Non-Par providers may accept assignment on a case-by-case basis or bill up to the Limiting Charge (115% of the Non-Par approved amount) if they do not accept assignment.
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The ABN is not an opt-out. It simply notifies the patient they may be responsible for services Medicare may not cover.
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Participation decisions affect your revenue cycle. Consider cash flow, patient out-of-pocket costs, and administrative processes when deciding status during open enrollment.
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Massachusetts-specific fee schedules show clear differences in patient responsibility and provider reimbursement depending on Par vs. Non-Par choices.
