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What to Do When Your Doctor Doesn't Take Medicare

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By Daniel Petkevich
Feb 24, 2023

Simple Strategies to Manage Your Out-of-Pocket Costs

Navigating your medical expenses can be overwhelming, and it becomes even more challenging if your doctor doesn't accept Medicare.

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Let's look at how healthcare providers approach Medicare beneficiaries and what you can do when your doctor doesn't take Medicare.

Do All Doctors Accept Medicare?

No. Not all doctors accept

Medicare.

While some physicians may choose not to participate in the Medicare program, others may limit the number of Medicare patients they are willing to accept.
Some physicians may deny Medicare due to the following reasons:
  • Tedious paperwork — Tasks like paperwork, compliance checks and claims filing may burden smaller medical practices, leaving less time for patient care
  • Low reimbursement — For some physicians, the actual cost of the care provided is much higher than the reimbursed rate. In addition, the

    2023 Physician Fee Schedule (PFS)

    brings a potential reduction in Medicare fees for physicians ranging from 4.5% to 8.5%.
  • Stringent rules — Some doctors may not be able to comply with Medicare's strict rules
Before receiving medical care, it's essential to confirm that your healthcare provider accepts Medicare to avoid unnecessary out-of-pocket expenses.

How Doctors Approach Medicare Patients

If you're enrolled in Original Medicare, a significant factor that determines your Part B cost (after you've paid the deductible) is the type of provider you choose. Medicare classifies providers into three types.
Physicians or healthcare providers can register with Medicare as a:

1. Participating Provider

These providers accept "assignment" on all Medicare claims for their Medicare patients, which means they agree to accept Medicare’s approved amount as full payment for all covered services. Almost

98%

of doctors that bill Medicare are participating providers. 
When you receive care from a participating Medicare provider, you're only responsible for the cost-sharing amount required by Medicare. This means if you're on Original Medicare, you'll have to pay:
  • The Part B deductible, and
  • 20% of the Medicare-approved amount (coinsurance)

2. Non-Participating Provider

These providers accept Medicare patients but can choose to accept Medicare assignments on a claim-by-claim basis. Unlike participating providers, they're limited to only 95% of the Medicare-approved amount if they accept a Medicare assignment. 
In contrast to participating providers, non-participating providers can charge beneficiaries more than the Medicare-approved amount (not exceeding 15% of the fee-schedule allowed amount) — also known as the limiting charge. 
If you're seeing a non-participating provider, you'll have to pay for the following:
  • The

    excess charges

    — the amount above the Medicare-approved amount for a service
  • 20% of the Medicare-approved amount (coinsurance)

3. Opt-Out Provider 

These providers don't accept Medicare at all. They have private contracts with their Medicare patients, which allow them to set their prices for services without limitation. Fortunately, only a small number of doctors have chosen to opt out of Medicare
If you're seeing a provider who opted out of Medicare, you’ll be responsible for 100% of the cost of the service. You may also need to sign an agreement to be accountable for the total cost of your care, and neither you nor your provider can send a bill to Medicare for payment.

What to Do When Your Doctor Doesn't Accept Medicare

While healthcare providers across the country widely accept Medicare, your doctor might not, which may limit your access to the medical care you need.
Here are a few steps you can take if your physician doesn't accept Medicare.

1. Remain with Your Current Provider and Pay the Difference

If your doctor is a non-participating provider who chooses not to accept Medicare assignments, they may charge you more than the Medicare-approved amount for their services.
If you want to continue seeing your current doctor, you'll likely have to pay the difference between the fee charged and the Medicare-approved amount.
Note: You may even have to pay the entire bill during your doctor's visit and submit a claim to Medicare. To request reimbursement for the portion of the bill approved by Medicare, you or your doctor can submit

Form CMS-1490S

.
For example, suppose your non-participating doctor charges $200 for a specific service, but the amount approved by Medicare for that service is only $150. If your doctor agrees to accept the Medicare assignment, you'll pay the difference of $50 — in addition to the 20% coinsurance for the service, which amounts to $30.
Here's the math:
$50+ 20% ($150) = $50 + $30 = $80

2. Ask for a Referral

If continuing to see your non-participating doctor is not feasible due to financial constraints, it's worth asking your doctor to recommend another physician in your area who accepts Medicare.
Chances are your current doctor has encountered this situation before and may have already made arrangements to transfer Medicare patients to another doctor.
By asking for a referral, you may be able to maintain continuity of care and avoid the potential difficulties of finding a new physician on your own.

3. Ask for a Discount

If your doctor is a non-participating provider or has opted out of Medicare, and the cost of the medical service is not within your financial means, you can ask for a discount.
Some physicians may be willing to lower their rates for established patients. They may offer extended payment plans for patients needing expensive treatments or procedures.

4. Visit an Urgent Care Center or Walk-In Clinic

Urgent care centers are medical facilities that provide walk-in medical care for people who need to see a healthcare provider but can't get an appointment with their

primary care physician

. These centers offer various medical services, including treatment for non-life-threatening illnesses and injuries, lab services, X-rays, and other diagnostic tests.
Many urgent care centers and walk-in clinics accept Medicare and even serve as primary care practices for some patients.
If you're experiencing a minor illness, require a flu shot, or need a diagnostic test, visiting one of these clinics may be more cost-effective than scheduling a traditional doctor's appointment. You can save your doctor visits for more serious medical conditions.

5. Refer to the Physician Compare Directory

The

Physician Compare Directory

, an online resource provided by the Centers for Medicare and Medicaid Services (CMS) in the United States, allows you to search for physicians and other healthcare providers who accept Medicare.
Once you’ve selected a physician, we recommend you confirm with the provider's office to ensure they're still taking new Medicare patients, as this can change anytime.
You can also ask nearby hospitals whether they have doctors who accept Medicare.

6. Concierge Care

Concierge medicine is a healthcare model in which patients pay an annual (around $1,500) or monthly fee to a primary care physician or healthcare practice in exchange for personalized medical care and services. It includes several benefits like same-day or next-day appointments, 24/7 access to their doctor, personalized health and wellness plans, and coordination of specialist care.
Concierge Doctors may accept Medicare assignments, but you'll have to pay for the annual membership, as Medicare doesn't cover this cost. If you can afford it and anticipate regular doctor visits, concierge medicine is worth considering.
Here are some key points to think about when signing up for concierge care:
  • If your doctor accepts Medicare assignments, they cannot charge you extra for Medicare-covered services. This means your membership fee can’t include additional charges for items or services that Medicare usually covers unless Medicare won’t pay for that item or service.
  • If your doctor doesn't accept Medicare assignments, they may charge you more than the Medicare-approved amount for their services. But this amount should not exceed 15% of the Medicare-approved amount.
  • All Medicare doctors (whether or not they accept assignments) can charge you for services that Medicare doesn't cover. Review your specific plan's coverage for any additional fees associated with concierge care.

What's The CARES Act of 2020?

The Coronavirus Aid, Relief, and Economic Security (

CARES

) Act is a law the United States Congress enacted in response to the COVID-19 pandemic. The CARES Act was designed to provide financial assistance to individuals, businesses, and healthcare providers affected by the pandemic.
A few changes brought about by The CARES Act:
  • Improved Medicare coverage to incorporate

    COVID-19 testing

    , treatment, and services for beneficiaries. Medicare covers 100% of the COVID-test costs, including COVID-19 antibody (or “serology”) tests.
  • Telehealth services under Medicare are now more flexible, which enables individuals to obtain medical care while adhering to social distancing guidelines.
  • Medicare now certifies physician assistants, nurse practitioners, and certified nurse specialists to provide home health services to Medicare beneficiaries.
  • Medicare has increased payments for COVID-19 hospitalizations and medical equipment to help healthcare providers cover the costs of caring for COVID-19 patients.
Under the CARES Act, states that have not expanded Medicaid can still use the program to provide COVID-19-related services for uninsured adults who would've been eligible for Medicaid if their state had chosen to expand its coverage.
Other people with limited Medicaid coverage may also qualify for coverage under this option.

Stay Informed to Overcome Healthcare Challenges

It can be challenging to navigate your medical expenses, especially if your doctor doesn't accept Medicare.
Despite Medicare's widespread acceptance among healthcare providers, some doctors still choose not to participate.
You can explore several practical solutions to get the care you need.
Whether it's finding alternative providers, negotiating rates, or asking for a referral, options are available.
At

Fair Square

Medicare

, we empower you with the knowledge and resources you need to make informed decisions about your health care. If you have any questions or concerns about Medicare, call us at 1-888-376-2028. Our team of expert advisors can provide personalized assistance and guidance.

Stay Up to Date on Medicare!

Join the Fair Square Medicare Newsletter to stay informed on cost savings, changes to Medicare, and other valuable healthcare information.

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