Is My Doctor Required To Accept Medicare?


When all the political chest-thumping and religious altruism is stripped away, medicine is just a business, like any other.  The brightest minds in our country understand that people are willing to pay big money to maintain their health.

If you want to see altruism in action, take a look at the underpaid hospital nurse or Home Health Aide. Their reward is to see the small improvements in one of their patients.

Doctors and hospitals are different.  Of course they enjoy seeing their patient’s recover.  They just enjoy seeing their financial profits more.  The days of a doctor being willing to barter for his services are over.  Today, if you cannot pay   cash to the doctor, he will just charge someone else.  The practice is called, “cost-shifting.”  One way or the other, your doctor or hospital is going to find a way to get paid.

If you have ever spent any significant time with the elderly, you know that health care is a common topic.  Unless there is an underlying disease their minds remain sharp as they age.  I wish that I could say the same thing about their bodies.  As people get older they often have to rely on medical care.  That care costs money.

Here in the United States, the most common source of payment for health care for those over age 65 is Medicare.  There is still some fear and confusion over the status of people’s doctor when they enroll in Medicare.  During the last half of the year, for the past 9 years, Americans have had to listen to threats from the American Medical Association and read stories of doctors who refuse to accept Medicare.

Unfortunately, many Americans think that means that doctors will not treat them.  That is not the case at all.  It just means that doctors will not accept the limitations Medicare has for payment.  As long as you have money, you will be able to find a doctor who will treat you.

In this post, I want to try to allay some fears and explain how doctor’s get paid.

PARTICIPATING (ACCEPT ASSIGNMENT)

The majority of doctors and hospitals are quite content to accept what Medicare will pay.  A physician who agrees to accept Medicare’s payment in full is called a Participating Physician.  The only money that he will collect from a Medicare beneficiary is your deductible and co-insurance.  He will file your claim with Medicare directly.

Keep in mind that Medicare B will not pay all your medical bill.  Medicare will only pay 80% of what your doctor charges, after you have paid your Medicare B deductible each year.  If you do not have a Medigap insurance plan or qualify for Medicaid as well, you will have to pay that additional 20% of the bill out of your savings.

NON-PARTICIPATING (15% EXCESS CHARGE)

A physician who does not agree to accept Medicare’s payment as full payment for his services is called a Non-Participating Physician.  He is allowed to charge more for his services.  His additional charge is called an “Excess Fee.”  His Excess Fee is limited to 15% of Medicare’s approved charge.

If you elect to use a Non-Participating doctor, you may be required to pay the doctor 115% of what Medicare says is a fair price.

Under the Social Security Act, a non-participating doctor is still required to file your claim with Medicare for you.  The difference is that rather than paying your doctor, Medicare will reimburse you directly for 80% of the Medicare approved amount.  After you get your reimbursement from Medicare, your net cost for your health care is only 35% of your doctor’s bill.

Some people buy Medicare supplement plans to pay what Medicare does not.  Some Medigap plans will pay both the 20% of the Medicare approved amount that you would normally pay plus any Excess Fees your doctor bills you.

OPTED OUT

Less than 2% of doctors have elected to completely ignore Medicare’s limits.  Some doctors and clinics have totally opted out of the Medicare system.  They are not limited by any of the Medicare rules.  They are free to charge whatever they want to charge for their medical care.  However, there are 2 restrictions that they must follow.

  1. They must collect directly from the patient.  They cannot bill Medicare or any other private insurance such as group health insurance or Medicare Advantage.
  2. They are required to form a written contract with their patients that meet the following criteria.
  • Contracts must be written large enough to ensure that the beneficiary is able to read the contract.
  • Contracts must be signed by the beneficiary or his legal representative and by the physician prior to any treatment.
  • Contracts must state that the physician has opted out of Medicare under the Social Security Act.
  • Contracts must state that the patient accepts full responsibility for payment of the physician’s fee.
  • Contracts must state that the patient understands that Medicare limits do not apply.
  • Contracts must state that the patient agrees not to submit a claim to Medicare or to ask the physician to submit a claim to Medicare.
  • Contracts must state that the patient understands that Medicare payment will not be made for any items or services furnished by the physician that would have otherwise been covered by Medicare.
  • Contracts must state that the patient enters into the contract with the knowledge of the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare.
  • Contracts must state the expected or known effective date and expected or known expiration date of the opt out period.
  • Contracts must state that the patient understands that Medigap plans do not make payments for items and services not paid for by Medicare.
  • Contracts may not be entered into by the patient during a time when the beneficiary requires emergency care services or urgent care services.
  • A copy of the contract must be provided (a photocopy is permissible) to the patient before treatment.
  • A copy of the contract must be kept by the physician for the duration of the opt out period.
  • A copy of the contract must be made available to the Centers for Medicare & Medicaid Services (CMS) upon request.
  • A new contract is required for each opt out period.

SUMMARY

When it comes down to it, many seniors who have Medicare B are worried about the wrong thing.  They do not need to worry that they cannot find a doctor to treat them.  They should be concerned about how that doctor wants to be paid.  The days of paying doctors with a chicken dinner and apple pie are over.  They expect, and deserve, to be paid money.  The question is, “How much money do they deserve.”

Other resources

Doctors and Medicare

Medicare Providers:  Participating vs Non-Participating

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