Tuesday, November 28, 2023

Can Doctors Limit The Number Of Medicare Patients

Don't Miss

How Much Does Medicare Pay For A Doctor Visit

‘What In The Heck Is Going On Here?’: Burgess Worries About Medicare Cuts

Everyone with Medicare is entitled to a yearly wellness visit that has no charge and is not subject to a deductible.

Beyond that, Medicare Part B covers 80% of the Medicare-approved cost of medically necessary doctor visits. The individual must pay 20% to the doctor or service provider as coinsurance.

The Part B deductible also applies, which is $203 in 2021. The deductible is the amount of money that a person pays out of pocket before the insurance begins to cover the costs.

A person will also need to pay a premium to keep the policy. The standard monthly premium in 2021 is $148.50.

If a person did not sign up when they were eligible at the age of 65 years, they might also need to pay a late enrollment penalty. This penalty can increase the premiums by 10% for each year that someone qualified for Medicare but did not enroll.

The costs associated with Medicare Advantage Plans vary depending on several factors, including:

  • whether the plan has a premium
  • whether the plan pays the Medicare Part B premium
  • the yearly deductible, copayment, or coinsurance
  • the annual limit on out-of-pocket expenses
  • the type of healthcare services a person needs

What Is A Provider Network

A provider network is a group of doctors, healthcare providers, and hospitals that a plan has a contract with, making them in-network.

A healthcare provider who has no contract with a plan is an out-of-network provider.

A private insurance company that offers Medicare Advantage policies may have different networks for different plans, so when a person searches for a healthcare provider online, it may be beneficial to ensure the correct plan is selected.

In-network providers can also be located by calling the insurer.

Your Doctor May Treat You But Refuse Medicare

There is another situation where your doctor may agree to treat you but refuse to bill Medicare. In that situation, you are responsible for the full bill.

Many medical practitioners that treat psychiatric conditions have opted out of the Medicare system.

A doctor that refuses to treat Medicare patients is well within their rights if they have opted out of Medicare.

Find out the facts BEFORE you make a mistake. Shop and compare Medicare plans in the comfort of your home.

Don’t Miss: Does Medicare And Medicaid Cover Dentures

Irked By Medicare Limits Doctors Ask Elderly To Pay Up

  • Send any friend a story

    As a subscriber, you have 10 gift articles to give each month. Anyone can read what you share.

    Give this article

A small but growing number of doctors, angry with the Federal Government’s limits on what they can charge for treating elderly patients, are finding ways to get around the Medicare rates by having patients pay extra fees, doctors, patients and Government officials say.

The practice, which usually involves doctors’ asking their elderly patients to sign contracts that result in added out-of-pocket payments, is drawing scrutiny from the Government and from advocates for the elderly. And Medicare officials have written to some doctors warning them that taking excess payment under contract leaves them open to prosecution, fines and sanctions.

Some of these private contracts stipulate that the patient will forgo Medicare coverage for a particular visit and pay out of pocket a fee set by the doctor. Others hold the patient financially responsible for future services that Medicare deems unnecessary and refuses to cover. Still others require patients to pay separately for services, like phone consultations, that Medicare considers part of the standard fee for office visits.

Although no one knows precisely how many doctors are using such contracts, Medicare officials say they are hearing more complaints.

Why Dont All Doctors Accept Medicare

Report: More doctors accepting Medicare patients

Often its not that they dont accept Medicare. Its that their practices are full. Let me explain:

Over the years there have been many scheduled cuts in doctor funding. Each time, Congress steps in at the last minute to kick the can down the road. This is good for our Medicare clients in the short-term, but does nothing to solve the long-term problem that Medicare is paying out more than it brings in. Eventually there will be a point where some President and Congress will need to be honest with Americans about the problems and provide real solutions.

One of the issues complicating the matter is that only about 3% of doctors coming out of med school are going into family practice. The great majority of doctors choose a specialty instead because they can earn nearly twice as high an income by doing so.

This shortage in primary care doctors is occurring at around the same time that the Baby Boomers are entering into Medicare. It has put further strain on an already overworked group of primary care doctors who accept Medicare. They can only see so many patients per day, and since Medicare reimburses them less than what they get for treating other non-Medicare patients, most doctors have to limit their practices to only so many Medicare patients.

So when you call these doctors, their office staff may say they arent taking Medicare patients when technically its that they arent taking any NEW Medicare patients.

You May Like: Does Medicare Cover Palliative Care For Dementia

Doctors Who Accept Medicare Assignment

Sometimes a beneficiary can find doctors who accept Medicare but have trouble locating one that accepts Medicare assignment.

Medicare has doctors who accept Medicare assignment and doctors that dont. Doctors who accept Medicare assignment can not charge you any balance bills, They accept Medicares payment in full. Some doctors are called non-participating. These doctors will see you if you have Medicare, but they reserve the right to send you a bill for an excess charge. This charge can be up to 15% more than Medicare pays.

Certain Medicare supplements will cover the excess charges for you. Then you dont have to worry about whether the doctor accepts Medicare assignment. For example, Plan F and Plan G do cover excess charges, but Plan N does not. People with Plan N need to ask every provider up front if he or she takes assignment. If not, they might get a bill that comes as a surprise.

There are a few states that do not allow doctors to charge excess charges. If you live in one of these states, a Plan N will function like a Plan F or G on the excess charges.

Why Do Doctors Charge More Than Medicare Pays

Doctors Who Opt-In and Charge You More

Doctors who do not accept assignment, on the other hand, believe their services are worth more than what the physician fee schedule allows. These non-participating providers will charge you more than other doctors. Medicare has set a limit on how much those doctors can charge.

Don’t Miss: Does Medicare Pay For Hospice At Home

Are The Costs Of Doctor Visits Different For Medicare Beneficiaries

What you pay will vary depending on whether your doctor is a Medicare participating provider, meaning they accept Medicares payment as payment in full. KFF found that 96% of Original Medicare doctors were participating providers, while 4% did not participate. Non-participating providers can charge patients up to 115% of Medicares rates, minus the amount Medicare pays. Medigap Plans F and G can cover these additional amounts, which are known as excess charges.

A small number of providers dont bill Medicare at all. Just over 26,000 providers have opted out of Medicare as of March 2020, which means they cant see Medicare beneficiaries without entering into a private contract where the patient agrees to pay full price. More specialists opt out of Medicare than other types of providers.

Are Medicare Doctors Taking New Patients

Shortage of Doctors accepting new Medicare patients

January 2, 2021 By Danielle Kunkle Roberts

Perhaps youve been feeling fearful about Medicare and wondering: Are Medicare doctors taking new patients? Fortunately, there are over 800,000 doctors who accept Medicare. In recent years there have been a lot of hype about doctors who accept Medicare and/or doctors who accept Medicare assignment. So of course, here at Boomer Benefits, we get many of questions, such as:

  • Do all doctors accept Medicare?
  • Is there a Medicare doctor shortage?
  • Will my doctor drop me when I transition to Medicare?

Lets put this worry to rest. More than 91% of all primary care physicians in the United States accept Medicare.

Don’t Miss: What Is Uhc Medicare Advantage

Fee Reductions By Specialty

The incidence of the Medicare and Medicaid fee reductions is more or less evenly distributed across primary care specialties, with internists doing slightly better on their office visits from Medicare and pediatricians and general practitioners doing somewhat better from Medicaid. Medicare fee reductions on office visits average 30-35 percent except for OB-GYN’s whose fee reduction is more than 40 percent . The fact that surgical fees are discounted more heavily would also imply greater losses incurred by surgeons and obstetricians, generally, when relative procedure mix is taken into account.

Summarizing, we do find corroborative evidence that both Medicare and Medicaid pay significantly less than the physician’s usual fee for office and inpatient visits as well as for surgical and diagnostic procedures. Commercial insurers and Blue Shield pay considerably better, but even their fee reductions ran 20-30 percent in 1976-77, and they are likely to be higher today. Clearly, the public programs are not alone in denying physicians at least part of their usual charges.

How To Find A Doctor Who Accepts Medicare

The Medicare website has a resource called Physician Compare that you can use to search for doctors and facilities enrolled in Medicare. You can also call 800-MEDICARE to speak with a representative.

If youre enrolled in a Medicare Advantage plan, you can call the plan provider or use their member website to search for a doctor.

For most of these tools, you can usually browse for a medical specialty, a medical condition, a body part, or an organ system. You can also filter your search by:

  • location and ZIP code
  • hospital affiliation
  • doctors last name

In addition to online tools or calling your insurance provider, you should also call the doctor or facility to confirm that they take Medicare and are accepting new Medicare patients.

You May Like: Is Wellcare The Same As Medicare

Medicare Part A Lifetime Limits

Medicare Part A covers hospital stays for any single illness or injury up to a benefit period of 90 days. If you need to stay in the hospital more than 90 days, you have the option of using your lifetime reserve days, of which the Medicare lifetime limit is 60 days.

Each lifetime reserve comes with a Part A hospital coinsurance payment of $778 in 2022. Once theyre gone, you may be responsible for 100% of your hospital costs.

Visit An Urgent Care Center

One In Five Doctors Say: âNo New Medicare Patientsâ?

Urgent care centers have become a popular place for people to go for their healthcare needs. There are now more than 9,000 urgent care centers in the U.S. These centers may also operate as walk-in clinics. Many provide both emergency and non-emergency services, including the treatment of non-life-threatening injuries and illnesses, as well as lab services.

Most urgent care centers and walk-in clinics accept Medicare. Many of these clinics serve as primary care practices for some patients. If you need a flu shot or you’ve come down with a relatively minor illness, you may consider going to one of these clinics and save the doctor visits for the big stuff.

Read Also: What Is Part D For Medicare

Doctor Charged Medicare For Treating 500 Patients In One Day

One doctor billed the taxpayer for seeing more than 500 patients in a single day, and more than 200 patients on several other days, according to the Medicare watchdog.

The case is in the annual report of the Professional Services Review agency, which disciplines doctors for inappropriate practice.

Investigation: Doctors were required to repay a total of more than $1.5 million.Credit:Jim Rice

The doctor, who worked for a company that provided workplace health and safety services, including vaccinations, told the agency they had ”eyeballed” each patient.

A GP who provides 80 or more services on 20 or more days of the year is generally considered to be guilty of inappropriate practice, because professional bodies say it is not possible to effectively treat such large numbers of patients.

The doctor, whose details are not disclosed, billed Medicare for 90 or more services on 29 days, potentially running up a bill of several thousand dollars in inappropriate services. The doctor negotiated a confidential settlement with the agency, which included an acknowledgement that they had engaged in inappropriate practice.

Over the year, 26 doctors were required to repay a total of more than $1.5 million and 11 were suspended from Medicare.

Stay Put And Pay The Difference

If your doctor is what’s called a non-participating provider, it means they haven’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 disagrees with the program’s reimbursement rates. These non-participating providers can charge 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. If you want to be paid back afterward, either your doctor will submit a claim to Medicare, or you may have to submit it yourself using Form CMS-1490S.

Let’s say, for example, your doctor’s bill comes to $300, and Medicare pays $250. This means you’ll have to pay the $50 difference, plus any copay, out of pocket, assuming your doctor agrees to the program’s reimbursement rates. This can add up quickly over time. However, you may be able to cover these extra expenses through a Medigap insurance policy, aka Medicare Supplement Insurance. Provided by private insurers, it is designed to cover expenses not covered by Medicare.

Recommended Reading: Does Medicare Cover Erectile Dysfunction Pumps

Do All Doctors Accept Medicare Advantage Plans

No they do not. Each Medicare Advantage plan has its own network of doctors and hospitals. If you enroll in a Medicare HMO, you must see doctors in the network except for in emergencies. Going outside the network will generally result in you paying for those services 100% out of pocket unless it was emergency care.

On Medicare HMO-POS or Medicare PPO plans, you have a bit more flexibility. You can see doctors out side the network at a higher cost to you, but first you must ask if that doctor is willing to bill your Medicare Advantage plan. He does not have to .

More Medicare Less Health Care: How Medicare For All Threatens Patient Health

CMS Physician Compare Patient Story

It is a bipartisan notion that American health care is in dire need of reform. American health care spending constitutes 18 percent of the gross domestic product of the largest national economy on the planet. By contrast, the country that is number two in GDP spent on health care is the immensely wealthy nation of Switzerland, whose health care spending comes in at only about 12 percent of its GDP, according to data from the Organisation for Economic Cooperation and Development.

One reason we spend so much on health care relative to other countries is that the United States is a hub of medical innovation and technology. New procedures and experimental drugs provide great value to American patients, but we pay more to obtain them. Differences in health statuses of national populations also account for some of the variance in health care outlays. Our superior cancer survival rates speak to the immense economic and social value we place on the individual life.

At the same time, insurance premiums have been climbing inexorably for decades, leaving Americans desperate for relief and policymakers searching for answers. Decades of legislative and regulatory interaction between the government, health insurers, and hospitals have drained massive amounts of value from the U.S. system.

Medicare Already Distorts Health Care

Fee-for-Service Medicare Provides Less Value than Private Plans

Medicares Price Controls Make It Harder to Find Care

Real Solutions

Key Topics

Read Also: Who Can Get Medicare Insurance

Not All Doctors Accept Medicare Heres Why That Matters

According to the Centers for Medicare and Medicaid Services most doctors will accept Medicare. This means that they will:

  • Accept Medicares guidelines as the full payment for bills
  • Submit claims to Medicare, so you only have to pay your share of the bill

To become participating Medicare doctors, according to CMS, they must sign an agreement with Medicare. That means they need to follow the rules for any medical services they provide you with. This also applies to other medical providers, like nurse practitioners, nutritionists, and therapists.

In other words, Medicare doctors only ask you to pay coinsurance or copays and/or deductibles when you visit. They will send a claim to Medicare for their portion of the cost. They also cant add an extra charge for agreeing to submit your claim for you.

Your costs are generally lowest if you get your services from a Medicare-participating doctor or provider. Participating providers agree to accept assignment for all Medicare-covered services, meaning that they will not charge you above the Medicare-approved amounts for a service. Youll still be responsible for any cost sharing that may apply, such as copayments, coinsurance, or deductibles.

Milestone Or Millstone Medicare Access In Midsize Metros

Jesse G. OShea, MS Kenneth Brummel-Smith, MD Suzanne Baker, MA LaVon Edgerton, BA

Abstract: There has been an overall decline in the number of physicians who accept patients with Medicare. Consequently, patient access has declined. Understanding Medicare trends can help inform policymakers of potential access problems, aid business efforts, and also direct healthcare resources in their recruitment of physicians. In this commentary, the authors describe the results of their study, which assessed recent Medicare access trends at a local level, specifically in a midsize metropolitan city and the possible social desirability bias with physician reporting in Medicare surveys.

Key words: Medicare, access to care, primary care, acceptance.__________________________________________________________________________________________________

When it comes to Medicare, physicians can presently choose from one of three options: to be a participating physician, which are those who accept assignment to be a nonparticipating physicianthose who do not accept assignment, but can bill their patients up to 15% more and can request payment up front or to be a provider who has legally opted out of Medicare.





  • Gunderson A, Menachemi N, Brummel-Smith K, Brooks R. Physicians who treat the elderly in rural Florida: trends indicating concerns regarding access to care. J Rural Health. 2006 22:224-228.
  • Affiliations:

    Recommended Reading: How To Pick A Medicare Plan

    More articles

    Popular Articles