Medicare is the federal health insurance program offered to certain populations, specifically to the population of age 65 and older. While many healthcare providers accept Medicare, there are still some doctors that do not. While this can be very frustrating for patients, there are a number of reasons why some doctors may accept Medicare and others do not. Read on to learn more.
The contract between Medicare and doctors is called Medicare Assignment, and it is the only way of identifying which healthcare providers accept Medicare from which do not. Medicare Assignment suggests that healthcare provider is required by law to accept previously determined Medicare-approved amount as full payment for given services. That significantly reduces out-of-pocket costs and prevents the provider from charging you beyond what Medicare covers for certain services.
Each medical provider can decide for themselves if they want to participate in the Medicare program or not. If a doctor at a local clinic doesn’t wish to participate, they can choose not to if they receive payments in their name, and they become a non-participating provider. If they receive payments through the hospital, they will be at the mercy of the hospital’s decisions. There are also situations where doctors had a private contract with Medicare but because of some reasons, they decided to terminate it and become opt-out providers.
A doctor who doesn’t accept Medicare Assignment can charge up to 15% above the Medicare-approved amount for a medical service. You will be responsible for the additional charge, on top of your regular 20% share of the cost from Original Medicare (and don`t forget about your monthly premiums).
Now that we learned about Medicare Assignment, let`s see the 3 main reasons why some doctors do not accept Medicare.
1. How Reimbursement Works
In order to understand why some medical practitioners do not accept Medicare, you must first understand how Medicare pays doctors. Medicare and doctors come to an agreement for each service – Medicare Assignment. A current doctor will bill a certain amount for a service, and Medicare will pay them back for that Medicare-covered service. When Medicare pays that primary care physician, it is called a reimbursement. There are certain rules that doctors must follow in order to be reimbursed.
One of the biggest reasons that doctors do not accept Medicare is that it does make financial sense for them to accept it. Compared to private insurance companies, Medicare only pays doctors 80% of what private health insurers would regularly pay for different services. It also often takes time to reimburse doctors. Medicare is notorious for its reimbursement delays. For some doctors, especially those who own their own private practice, the combination of delayed reimbursement and decreased reimbursement is too much. Some of these doctors could not operate their businesses if they accept Medicare.
3. Overbearing Rules
In order to receive reimbursement, physicians must abide by a certain set of rules. These rules can require a lot of paperwork and staff to handle that paperwork. They can also be confusing and difficult to follow. Sometimes these rules require that the doctor do certain tests or follow certain protocols even if those tests and protocols do not make sense for that patient. For example, there are different incentive programs to encourage doctors to improve patient outcomes. While this is a good thing in theory, in practice it can be difficult to carry out. It may also be impossible depending on the population of patients that the doctor treats. If doctors do not meet certain targets, they may face penalties. These stringent requirements can take some of the art out of the art of medicine, so some physicians prefer to avoid Medicare altogether.
Finding a doctor who accepts Medicare is normally easy, but some doctors choose not to participate in the program. The only way to prevent surprise charges is to ask clearly your health care provider if they accept Medicare Assignment. To learn more about your options, contact Temmen Insurance today.