“What happens when you sign up for Medicare, only to learn your all-time favorite doctor doesn’t accept it?”
Let’s say you’ve been going to the same doctor for 30 years. She knows you inside and out (literally). Dr. Doe is totally familiar with your medical history. She has a great bedside manner and a friendly, efficient staff. However, it turns out the doctor doesn’t take Medicare!
Investopedia’s recent article, “Do This When Your Doctor Doesn't Take Medicare,” explains that if your long-time doctor “accepts assignment,” it means he or she agrees to accept Medicare-approved amounts for medical services. That’s super. All you’ll need to pay is the annual Medicare Part B deductible ($183 a year in 2018) and a 20% co-pay for every visit.
However, with the federal program’s low reimbursement rates, restrictive rules, and arduous paperwork process, many physicians are refusing to accept Medicare’s payment for services. Look at the numbers: In 2000, almost 80% of the Texas Medical Association’s doctors were taking new Medicare patients. In 2012, that number dropped to fewer than 60%.
More doctors are turning down Medicare, because it typically pays doctors only 80% of what private health insurance pays. While a gap always existed, many physicians feel that in the past several years Medicare reimbursements haven't kept up with inflation (especially the expense of operating a medical practice), while the rules and regulations keep getting stricter, along with the penalties for non-compliance.
Here's what you can do, if your doctor doesn’t accept Medicare:
- Stay with Your Physician and Pay the Difference. If your doc’s what’s known as a “non-participating provider,” it means she hasn’t signed an agreement to accept assignment for all Medicare-covered services but could still choose to accept assignment for individual patients. Therefore, Dr. Doe may take Medicare patients, but she doesn’t agree to Medicare’s reimbursement rates. These non-participating providers can charge you up to 15% over the official Medicare reimbursement amount.
If you stay with your non-participating doctor, you’ll have to pay the difference between the fees and the Medicare reimbursement. You may also have to pay the entire amount of the bill during your office visit. If you want to get reimbursed, either your doctor will submit a claim to Medicare or you may have to submit it yourself.
- Ask for a Discount. If your doctor is what’s termed an “opt-out provider,” she may still be willing to take Medicare patients, but she expects to be paid her full fee, not the much smaller Medicare reimbursement amount. These doctors accept no Medicare reimbursement, and Medicare won’t pay for any part of the bills you receive from them. You’ll be responsible for paying the full bill out of pocket. These opt-out doctors must disclose the charges for all their services up front. These doctors will also have you sign a private contract saying you consent to the opt-out method.
You can try to negotiate a discount. It's not unheard of for physicians to lower their rates for established patients. They might also offer you some payment terms, as a courtesy if you require expensive treatments or procedures.
- Try a “Doc in the Box.” Many urgent care centers and walk-in clinics take Medicare.
- Get a Referral. If you can’t afford to remain with your doctor, ask her to recommend the next best doctor in town who does accept Medicare.
- Start Looking. There are many doctors who take Medicare. You can find them in Medicare’s Physician Compare directory. When you find a provider, contact them to see that they’re still taking new Medicare patients.
If you recently enrolled in Medicare and now see that your long-standing doctor doesn’t accept it, you have several options. Whether you decide to stay with your doctor and pay the price, or switch to a new doctor, do the homework. Consider your decision in light of your health. If you have a specialized health issue and your doctor makes a difference, it may be worth spending the money for better care and peace of mind.
Reference: Investopedia (June 14, 2018) “Do This When Your Doctor Doesn't Take Medicare”