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  • Wiser Medicare

What to do if your doctor isn’t in your Medicare network?

When my former employer switched health insurance companies, there was a frenzy among the staff to make sure our doctors were in the new insurance company’s network. No one wants to have to look for a new general practitioner or specialist if they already have one, but on the flip side, no one wants to pay for out of network medical visits and procedures unless they have money to burn.

The same is true with Medicare, where doctors may choose to fully participate, participate but not accept Medicare reimbursement as full payment, or opt out of the system entirely. Approximately 20,000 doctors nationwide have made that decision. For patients with Medicare Parts A and B, any doctor who accepts Medicare should take your Medicare. With Medicare Advantage Plans, only doctors in their network may accept your Medicare.

The first thing to do, therefore, is make sure your doctor accepts your Medicare. If you see different doctors at the same hospital, some may take it, and some may not. To find out if a doctor accepts Medicare, go here. It’s good to then double-check with the physician, because he/she might have stopped accepting new patients with Medicare at some point, but continued to see longtime patients with Medicare. If you thought that your doctor accepted your Medicare and found out otherwise when you got the bill, there may be options available to you. In New York, for instance, there are consumer protections in place for patients who get surprise bills. That may be true in your state also. Or you may be able to work out a payment compromise with the doctor if you explain the misunderstanding.

Why would a doctor choose to not be part of Medicare, a plan that insures tens of millions of older Americans?

Freedom. For doctors who see patients with means to pay, opting out of Medicare can mean higher fees, more time with patients, less paperwork, faster payment times, smaller staff and overhead, and not having to deal with the stressors caused by a large, government bureaucracy.

What can you do if you now qualify for Medicare and your doctor doesn’t accept it?

The first, easiest thing is to decide how much you like your doctor. If you don’t want to change doctors, talk. While it will be more difficult to negotiate with a surgeon (who has operating room, staffing and anesthesia expenses beyond his/her control), if you’ve been seeing your general practitioner for a long time and trust their care and advice, you may be able to work out a cash price you both can live with.

Let’s say your GP charges $100 for an office visit. Medicare’s reimbursement will be less than that and it will require forms filled out and may take weeks or months to get paid. The GP may be willing to take $50-$60 in cash or check and have the money that day with no headaches. It’s worth asking. If you don’t like your doctor, no problem. You can ask the doctor for a referral to a physician who accepts Medicare, ask friends for recommendations, go online and check out reviews for doctors in your neighborhood, or visit your neighborhood urgent care. Virtually all of them accept Medicare.

And to be fair, most doctors also accept Medicare. According to a study by the Kaiser Family Foundation, “One percent of all non-pediatric physicians have formally opted-out of the Medicare program in 2020, with the share varying by specialty, and highest for psychiatrists (7.2%).”

That survey doesn’t tell the whole story, however. While the vast majority of family practice doctors accept Medicare, less than 4/5ths of those doctors will accept new patients on Medicare. It’s therefore important to be very clear when asking the question if your doctor will accept a Medicare payment from you.

Lastly, we’re going to add in one more complicating factor: The non-participating provider. That’s a doctor who sees Medicare patients but does not accept Medicare reimbursements as payment in full. With these doctors, the patient, will have to make up the difference between the Medicare reimbursement rate and the doctor’s stated rate. The good news here is that Federal government regulations prohibit a patient’s up-charge of more than 15% over the Medicare reimbursement rate (some states mark that down further). If Medicare pays $60 for that $100 visit, you could be responsible for another $9 (15% of $60).

If your doctor has opted out of Medicare, you’re responsible for the whole bill, but you must be informed of this before the visit.



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