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What to Do If Your Doctor Doesn't Take Medicare
What to Do If Your Doctor Doesn't Take Medicare

Health Line

time02-06-2025

  • Business
  • Health Line

What to Do If Your Doctor Doesn't Take Medicare

If a doctor doesn't accept Medicare, you can choose to see them and pay more, or you can find a different provider. Medicare has an online directory of participating providers. When you're enrolled in Medicare and looking to get medical care, it's important to check whether the healthcare professional you want to see is willing to work with the insurance program. Many doctors work with Medicare. Those who do not may be nonparticipating providers or opt-out providers. Nonparticipating providers may sometimes accept assignment, but they may not at other times. Opt-out providers never accept Medicare. Read on to learn what to expect and what to do when your doctor will not take Medicare. What happens if a doctor doesn't accept Medicare? A doctor who works with Medicare is referred to as accepting assignment. This means the provider is willing to accept Medicare reimbursement. If you see a doctor who does not accept assignment, you'll have higher out-of-pocket costs than with a participating provider. In this case, your choices are as follows: See a different doctor: Switch to a different doctor who works with Medicare. Go to urgent care: Depending on your medical needs, you could schedule an immediate care or walk-in visit with a doctor who accepts Medicare. This may be easier and faster than scheduling a regular appointment. Most urgent care centers should accept Medicare. You can speak with the care center staff to learn whether the facility accepts Medicare. Proceed and pay extra: You might make this decision, for example, if you need to see a specific specialist and no similar specialist is accepting assignment. In this case, you can consider asking the staff if there are any discounts or payment plans that you might be eligible for. Submit claim: If you do proceed with seeing a nonparticipating doctor who does not accept assignment, they will submit a claim for any portion of the service they will directly bill to Medicare. In some cases, you may be asked to pay upfront and submit the claim yourself. How much does it cost to see a doctor who doesn't accept Medicare? Medicare nonparticipating providers can choose individually whether to accept the Medicare-approved rate for covered services. This amount is what Medicare reimburses them for services under Medicare Part B. If they do not accept this rate, they can charge you up to 15% more than the approved rate. The exact percentage varies by state and is called the 'limiting charge.' Note that this surcharge rule does not apply to durable medical equipment (DME), which means DME suppliers can charge more than the limiting charge. When it comes to opt-out providers, since they do not accept Medicare at all for any service, they will bill you directly for all costs unless you have a secondary health insurance plan that they do accept. Is it hard to find doctors who accept Medicare? It's not difficult to determine whether a doctor works with Medicare. To find out if a doctor accepts Medicare assignment, consider asking your current doctor's office for a referral to someone who does accept assignment. You can also use the Medicare provider directory on the website. Alternatively, you can call 800-MEDICARE (800-633-4227) or the specific doctor's office and ask before you schedule the appointment. In addition, representatives from the State Health Insurance Assistance Program (SHIP) may be able to assist you in the search. Why would a physician opt out of Medicare? Whether to accept an assignment depends on each doctor or clinic. Doctors who opt out of Medicare can set their own fees and avoid Medicare billing rules, audits, prior authorizations, and documentation requirements, gaining greater flexibility and reducing their administrative responsibilities. Nonparticipating providers, in particular, can decide on a case-by-case basis whether to accept Medicare rates or bill you directly at higher rates for certain services. In high cost areas or when their patients indicate that they can pay out of pocket, nonparticipating providers may earn more than participating providers when they don't accept assignment. On the other hand, when nonparticipating providers file a Medicare claim, they receive a payment that is 5% lower than the amount permitted by the Medicare physician fee schedule. This means they earn less than participating providers when they consent to accept assignment. Frequently asked questions What percentage of doctors do not accept Medicare? As of 2024, only about 1% of non-pediatric physicians had opted out of Medicare altogether, with psychiatrists leading at 8.1%. Opt-out rates are notably low for emergency medicine, oncology, radiology, and pathology, all at 0.1% or less. Psychiatrists, on the other hand, make up the largest portion of those opting out, followed by family and internal medicine physicians. As of 2024, only about 1% of non-pediatric physicians had opted out of Medicare altogether, with psychiatrists leading at 8.1%. Opt-out rates are notably low for emergency medicine, oncology, radiology, and pathology, all at 0.1% or less. Psychiatrists, on the other hand, make up the largest portion of those opting out, followed by family and internal medicine physicians. Do doctors have to accept Medicare Advantage plans? When considering nonparticipating versus opt-out providers, remember that these terms refer to doctors who may or may not accept Original Medicare (parts A and B). In addition, you have the option to enroll in a Medicare Part C (Medicare Advantage) plan instead, which would give you the same benefits. However, these are private insurance plans with their own network of providers. Depending on the type of plan, you may have to see an in-network provider. When considering nonparticipating versus opt-out providers, remember that these terms refer to doctors who may or may not accept Original Medicare (parts A and B). In addition, you have the option to enroll in a Medicare Part C (Medicare Advantage) plan instead, which would give you the same benefits. However, these are private insurance plans with their own network of providers. Depending on the type of plan, you may have to see an in-network provider. Why does Medicare pay less than the Medicare-approved amount? Every year, the Centers for Medicare & Medicaid Services (CMS) sets the rates for all physician services for the following year using a range of complex data sets and formulas intended to represent physician costs associated with practicing medicine, among other factors. That said, according to the American Medical Association, this formula does not adjust these rates for inflation, which may be another reason a doctor could decide to opt out of Medicare. Every year, the Centers for Medicare & Medicaid Services (CMS) sets the rates for all physician services for the following year using a range of complex data sets and formulas intended to represent physician costs associated with practicing medicine, among other factors. That said, according to the American Medical Association, this formula does not adjust these rates for inflation, which may be another reason a doctor could decide to opt out of Medicare. Do all doctors accept Medicare Supplement plans? Medicare supplement plans, also called Medigap, can be easily confused with Medicare Advantage. Doctors do not accept Medigap simply because it is not a medical insurance plan. Instead, Medigap helps cover remaining costs after Original Medicare coverage kicks in. Medicare supplement plans, also called Medigap, can be easily confused with Medicare Advantage. Doctors do not accept Medigap simply because it is not a medical insurance plan. Instead, Medigap helps cover remaining costs after Original Medicare coverage kicks in. Takeaway When you are enrolled in Original Medicare and need medical attention, it's crucial to verify whether the healthcare professional you wish to visit collaborates with the insurance program. Numerous doctors partner with Medicare, but some may not. Per Medicare guidelines, they are referred to as nonparticipating providers or opt-out providers. Nonparticipating providers might occasionally accept Medicare assignment, while opt-out providers never do. If a doctor does not accept Medicare, you have the option to still see them, but you will likely incur higher costs. You can also see a different provider. Medicare provides an online directory listing participating providers.

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