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What to Do When Your Doctor Doesn't Take Medicare

Author: Matthew Jackson

You've been going to the same doctor for 30 years, and he or she knows you inside and out (literally). Intimately familiar with your medical history, your beloved physician also has a wonderful bedside manner, a beautiful office and a friendly, efficient staff. So what happens when you sign up for Medicare only to learn your all-time favorite doc doesn't accept it?

It turns out this is an increasingly common occurrence. But there ways to deal with it.

A Bit of Background

A federal government-sponsored program, Medicare provides medical insurance for American citizens age 65 and over. President Lyndon B. Johnson signed Medicare into law on July 30, 1965, and by 1966, 19 million citizens had enrolled. Today, nearly 50 years later, that number has mushroomed to nearly 56 million, nearly 17% of the U.S. population.Over the next decade, as more baby boomers reach the age of 65, an additional 19.1 million people are projected to sign up for the program. It's no wonder Medicare benefit payments totaled a whopping $597 billion in 2014 and are projected to climb to $605.9 billion in 2015.

If your long-time physician accepts assignment, this means he or she agrees to accept Medicare-approved amounts for medical services. Lucky for you. All you'll likely have to pay is the annual Medicare Part B deductible ($147 per year in 2015) and a 20% co-pay for every doctor visit. As a Medicare patient, this is the ideal and most affordable scenario.

Yet thanks to the federal program's low reimbursement rates, stringent rules and grueling paperwork process, many doctors are refusing to accept Medicare's payment for services. Case in point: In 2000, nearly 80% of the Texas Medical Association's doctors were taking new Medicare patients. By 2012, that number dropped to less than 60%.

Why are more and more doctors turning down Medicare? The answer is simple: Medicare typically pays doctors only 80% of what private health insurance pays. While a gap always existed, many physicians feel that in the last several years, Medicare reimbursements haven't kept pace with inflation (especially the costs of running a medical practice), while the rules and regulations keep getting more onerous, as do penalties for not complying with them.

So what do you do when your doctor doesn't accept Medicare? Here are a five options to consider:

1: Stick with Your Doc and Pay the Difference

If your doctor is what's called a non-participating provider, this means he or she hasn't signed an agreement to accept assignment for all Medicare-covered services – but can still choose to accept assignment for individual patients. In other words, your doctor may take Medicare patients, but 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 choose to stick with your non-participating doctor, you'll have to pay the difference between the fees and the Medicare reimbursement. Plus, you may have to cough up the entire amount of the bill during your office visit. Then, if you want to get paid back, either your doctor will submit a claim to Medicare or you may have to submit it yourself using Form CMS-1490S.

So, let's say your doctor's bill comes out $300, and Medicare will pay $250. This means you'll have to pay the $50 difference, plus your 20% copay out of pocket. Obviously, this can add up quickly over time. However, you may be able to cover these extra expenses through a Medigap insurance policy (see Medigap Insurance: Who Needs It? for details).

2: Request a Discount

If your doctor is what's called an opt-out provider, he or she may still be willing to see Medicare patients, but expects to be paid her full fee – not the much smaller Medicare reimbursement amount. These docs accept absolutely no Medicare reimbursement, and Medicare will not pay for any portion of the bills you receive from them. That means you will be responsible for paying the full bill out of pocket.

Opt-out physicians are required to reveal the cost of all their services to you up front. These doctors will also have you sign a private contract saying you agree to the opt-out method.

Of course, you can always try to negotiate a discount. It's not uncommon for physicians to lower their rates for established patients. They might also offer, as a courtesy, extended payment plans if you're in need of a series of expensive treatments or procedures.

3: Go to a Doc in the Box

Most urgent care centers and walk-in clinics accept Medicare. According to the Urgent Care Association of America, there are more than 6,900 urgent care centers in the U.S., and many of these clinics serve as primary care practices for some patients. So, if you just need a flu shot or come down with a relatively minor illness, you may consider going to one of these places. Save the doctor visits for the big stuff.

4: Ask for a Referral

If you simply cannot afford to stick with your medico, ask him or her to recommend the next best doctor in town who does accept Medicare. Who else is better-equipped to make sure you fall into reputable, experienced hands? He or she might have already prepared for this eventuality and arranged to transfer Medicare patients to another physician's care.

5: Start Searching

There are still plenty of doctors who take Medicare. You can find them in Medicare's Physician Compare directory, a comprehensive list of physicians and healthcare providers across the nation. Once you pinpoint a provider, call to make sure they're still taking on new Medicare patients. After all, this can change on a dime. Another approach is to check the best local hospitals and see if any physicians on their staff are taking Medicare patients. When you get names, research them online to learn about their backgrounds.

The Bottom Line

Thanks to plummeting reimbursement rates, ever-tightening rules and cumbersome paperwork, many doctors are dropping Medicare like a bad habit. If you recently enrolled in Medicare, only to find that your long-standing doctor doesn't accept it, you have a number of options.

Also, just because you are eligible for Medicare doesn't mean you have to enroll in all four parts of it. If you have other health insurance – say, you're still working and can remain covered by your employer's group plan – it might be best to continue to use that. The Employee's Guide To Medicare provides more information on which employees can continue to use the office plan as their primary insurer. Medicare Advantage Plan networks are another alternative to investigate; physicians in those HMO-like plans have agreed to accept the network's fees.

Whether you choose to stick with your cherished physician and pay the potentially exorbitant price – or switch to a doctor who does accept Medicare, it's important to carefully crunch the numbers before you make a final decision. Also review your own medical situation and whether you need your current doctor (or someone with similar expertise) because of a specialized health issue.

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