Not all doctors accept Medicare for their patients, becoming more prevalent. This can result in larger out-of-pocket expenses than expected and a difficult decision if you like that doctor. So what to do if a doctor does not take Medicare?
What happens if you enroll in Medicare to find out that your favorite doctor doesn’t accept it? You do, however, have some options.
Takeaways:
- You won’t be charged more than the Medicare-approved price for authorized services if you choose a doctor who accepts Medicare.
- A doctor can be enrolled in Medicare, non-participating in Medicare, or opting out of Medicare.
- The Medicare status of your doctor influences how much Medicare covers and your alternatives for lowering costs.
What Is Medicare? When do doctors accept Medicare?
Medicare is a federally funded health-insurance program for anyone aged 65 and up in the United States. After being approved by the president on July 30th, 1965, Medicare was made official by the act. At the end of 1966, the program had signed up 19 million people from all over the country.
After more than 50 years, that number has risen to nearly 60 million, accounting for more than 18% of the US population.
Enrollment is predicted to reach 81 million in 2035 as more baby boomers reach retirement age. It’s no surprise that Medicare benefit payments in 2019 totaled $796 billion.
If your long-time doctor accepts the assignment, it means they’re willing to take Medicare-approved payment for medical services.
Medicare Part A covers inpatient hospital stays. Most Part A participants don’t pay a monthly premium because they paid into it through taxes, and there are no coinsurance payments for 60 days or fewer hospital stays. On the other hand, the yearly deductible for Part A is $1,484 in 2021 and $1,556 in 2022.
Part B of Medicare covers doctor’s visits, tests, physical therapy, and flu vaccinations. Most people’s Medicare Part B premium will be $148.50 per month in 2021 and $170.10 per month in 2022. The annual deductible for Part B is $203 in 2021 and $233 in 2022.
Is it Legal for Doctors to Refuse Medicare?
“Yes,” is the quick answer. Many physicians are declining to accept Medicare reimbursement for services due to the government program’s low reimbursement rates, rigorous rules, and lengthy administrative processes.
In most cases, Medicare only pays doctors 80% of what private health insurance pays.
While there has always been a disparity, many physicians believe that Medicare reimbursements haven’t kept up with inflation in recent years, particularly the increased costs of running a medical practice. Simultaneously, the rules and regulations become more onerous, as do the penalty for breaking them.
The majority of doctors in the US participate in Medicare and “accept assignment” (what Medicare pays) for their services without charging extra.
If your doctor refuses to participate in Medicare or has opted out, you have five options.
Stay in your current location and pay the difference.
If your doctor is a non-participating provider, they haven’t signed a contract agreeing to accept assignment for all Medicare-covered treatments. However, they can still accept it for individual patients. In other words, your doctor may accept Medicare patients but object to the reimbursement rates set by the program. Non-participating providers can charge up to 15% more than Medicare’s official payment rate.
You will have to pay the difference between the costs and the Medicare reimbursement if you opt to stay with your non-participating doctor. Furthermore, you may be required to pay the entire bill at your clinic visit. If you want to be reimbursed, your doctor will either submit a claim to Medicare on your behalf, or you will have to submit it yourself using Form CMS-1490S.
Consider the following scenario: your doctor’s bill is $300, and Medicare pays $250. If your doctor agrees to the program’s reimbursement rates, you’ll have to pay the $50 difference plus any copay out of cash. This can quickly build up over time. However, a Medigap insurance policy, often known as Medicare Supplement Insurance, may be able to cover these additional costs. Private insurance companies provide it and pay for things Medicare doesn’t cover.
Make a Discount Request.
If your doctor is an opt-out provider, they may continue to accept Medicare patients but demand full payment rather than the reduced Medicare reimbursement level. These doctors don’t accept Medicare reimbursement, and Medicare doesn’t cover any of the bills they send you. That implies you’ll be liable for paying the entire cost alone.
Opt-out doctors must tell you upfront how much all of their services will cost. Additionally, you will have to sign a private contract with these providers, indicating your approval of the opt-out arrangement.
However, you can always attempt to haggle for a lower price. It’s not uncommon for doctors to reduce their fees for long-term patients. They may offer extended payment plans as a courtesy if you need a succession of pricey treatments or operations.
Go to an Urgent Care Facility.
People are increasingly turning to urgent care services for their medical requirements. In the United States, there are already over 9,000 urgent care centers. These facilities could also serve as walk-in clinics. Many offer both emergency and non-emergency services and lab services, and the treatment of non-life-threatening injuries and illnesses.
The majority of walk-in clinics and urgent care centers accept Medicare. For some patients, many of these clinics serve as primary care practices. If you need a flu vaccination or mild sickness, you might want to go to one of these clinics instead of the doctor.
Seek a referral from your doctor.
If you can’t afford to keep your current doctor, ask them to refer you to the next doctor in town who accepts Medicare. Your current doctor has most likely planned for this possibility and arranged for Medicare patients to be transferred to another physician’s care.
Look through the Medicare Directory.
A large number of doctors still accept Medicare. They’re listed in Medicare’s Physician Compare directory, which has a complete list of physicians and healthcare providers across the country. Once you’ve found a physician, call them to see whether they’re still accepting new Medicare patients. After all, anything might happen at any time.
Another option is to check with the right local hospitals to see if their physicians accept Medicare patients. When you have a list of names, look them up on the internet to discover more about them.
The 2020 CARES Act.
President Trump signed the CARES (Coronavirus Aid, Relief, and Economic Security) Act, a $2 trillion coronavirus emergency stimulus package, into law on March 27th, 2020.
It increased Medicare’s ability to cover COVID-19-related treatment and services. The CARES Act also contains the following provisions:
- Allows Medicare to cover telehealth services with more flexibility.
- Allows physician assistants, nurse practitioners, and certified nurse specialists to certify home health services for Medicare.
- Increases Medicare payments for hospital stays and durable medical equipment related to COVID-19
The CARES Act reaffirms that non-expansion states can use Medicaid to provide COVID-19–related services for uninsured persons who would have qualified if the state had decided to expand. Under this state option, other populations with limited Medicaid coverage are also eligible for coverage.
Do all Doctors Accept Medicare?
Some doctors choose to opt out of Medicare for various reasons, including lower compensation rates, paperwork, and regulations.
What Can I Do If My Doctor Refuses to Accept Medicare?
You can choose to stay and pay for everything yourself, but this is not an option for most Americans. Rather than that, you can get a recommendation from your physician to a Medicare-accepting healthcare provider, perform your research, or visit an urgent care center. The majority of urgent care centers accept Medicare.
Why Don’t Doctors Accept Medicare?
For doctors, Medicare is not always cost-effective. It usually only pays doctors 80% of what private health insurance does.
Final Thoughts.
Many doctors are abandoning Medicare due to declining reimbursement rates, ever-tightening standards, and time-consuming paperwork. If you’ve recently registered for Medicare, but your long-time doctor refuses to accept it, you have a few options.
Whether you continue with your current doctor and pay the potentially excessive fee or switch to a doctor who accepts Medicare. It’s critical to do your homework before making a final decision. Examine your medical circumstances to see if a specific health concern necessitates seeing your current doctor—or someone with similar experience.
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