Medicare Doctors: In-network or Accepting?

Doctors interacting with senior patient

Now that you are enrolled in Medicare, you need to know which doctors to use that will allow you to utilize your federal benefits to the most total capacity. To maximize your benefits, you need to receive care from doctors who accept Medicare Assignment.

Many people don’t realize significant differences between Medicare doctors who are “in-network” and Medicare doctors who accept Medicare patients. In this article, we will discuss the differences and how they apply to your Medicare coverage.

The Exemplary Situation

You did what you are supposed to do. You called your doctor’s office and asked if they took Medicare. The receptionist who answered the call confirmed that with a yes, the office accepts Medicare patients. You think, that is a great news. You go to your appointment that you think is mainly covered by Original Medicare that you are part of. You plan to pay your copayments, but nothing more.

And then a bill arrives in the mail and the due amount is more than your copayment is supposed to be. You call back the office, thinking there must have been a mistake. The same receptionist tells you that no mistake has been made. Their office accepts Medicare patients and even files the claim on the individual’s behalf, but they do not accept Medicare Assignment. You’re stuck paying the bill in whole amount.

What went wrong? Were you lied to? Not quite, although it would have been much more professional of the receptionist to explain the differences between “accepting Medicare patients” and “accepting Medicare assignment” in the first conversation.

Providers Accepting Medicare Assignment vs. Providers Accepting Medicare Patients

Here is the breakdown of difference between doctors who accept Medicare Assignment and doctors who accept Medicare patients, but not Assignment.

Accepting Medicare Assignment means that the doctor will accept Medicare’s payment as part of a negotiated fee considered fair by both parties. That means you won’t be paying more than what your Medicare plan deems necessary to provide coverage for medical services and supplies. This applies to procedures covered under Medicare Part B.

In real-life situation it works like described in the continuation. A doctor who accepts assignment has agreed to accept the Medicare-approved amount as full payment for any covered service provided to a Medicare patient. The doctor sends the whole bill to Medicare. Medicare pays the 80% of the cost that it has decided is appropriate for the service, and you are responsible for the remaining 20%.

Even a doctor who does not accept Medicare Assignment can provide services for a Medicare beneficiary. Many will even file the claim for the patient. However, if they do not accept Medicare Assignment, they can charge up to 15% more than Medicare’s allowed fee. These are called Medicare overcharges (also referred to as “excess charges”). Excess charges occur when providers bill the patient for more than what Medicare has agreed to pay the provider.

For example, let’s say you go to the doctor and have a Medicare-approved procedure that costs $200 (according to Medicare.) If that doctor does not accept Medicare assignment, they can decide that $200 is insufficient reimbursement for that test. The doctor can choose to charge 15% more, which would amount to $30 ($230 total) for the test. This $30 is considered the Part B excess charge.

Experienced Medicare Doctors
Make sure you use that term specifically, “Do you take Medicare?”

Which Doctors Accept Medicare?

The only way to prevent excess charges is to ask your doctor if they accept Medicare Assignment. Make sure you use that term specifically and do not just ask, “Do you take Medicare?”

Remember, if you are scheduling a more extensive procedure like a surgery, there is likely more than one doctor involved – like an anesthesiologist. Be sure to ask if all the providers on your team accept Medicare Assignment. Often, it’s the specialists that members forget to inquire about.

The good news is, 95% of the doctors across the United States accept Medicare Assignment.

A doctor who doesn’t accept Medicare Assignment can charge up to 15% above the Medicare-approved amount for a service. You are responsible for the additional charge, on top of your regular 20% share of the cost (from Original Medicare). The doctor is supposed to submit your claim to Medicare, but it is possible that you will have to pay the doctor at the time of service and then claim reimbursement from Medicare retroactively.

Enroll in Medicare Supplement or Part C plan

Another option to ensure you do not pay Part B excess charges is to enroll in a Medicare supplement (Medigap plan) or Medicare Advantage (Part C) plan that covers those charges for you. There are many other things to consider when searching for a Medicare Supplement plan or Part C plan, but if the Plan offers benefits for excess charges, that is a bonus for the member.

Providers Who Opt-Out of Medicare

Some providers have entirely opted out of the Medicare system. If you see a doctor who has done this, neither the provider nor you will send a claim to Medicare as there will be absolutely no coverage for services rendered. You will pay the provider the full fee for their services.

An easy way to find out if your provider has opted out of Medicare is to search the national database on Medicare.gov.

One Last Consideration

If you decide to enroll in a Medicare Supplement plan or Part C plan, you will need to determine if you must receive care from an in-network provider. This is a separate qualification from accepting Medicare Assignment. Some plans only allow you to see in-network providers; otherwise, you may have no coverage if you go outside of your network. Others offer partial coverage for out-of-network services.

Again, be specific when you’re asking your provider this question. Don’t ask, “Do you take Company X patients?” Instead, ask, “Are you in-network with Company X?” This will ensure you get the answer you are looking for and don’t end up with surprises later, like in situation described in the beginning of this text.

Fortunately, doctors who do not accept Medicare assignments are rare. However, medical bills can quickly pile up, so doing your homework regarding your healthcare team is an essential component of controlling the cost of your healthcare.

Owner at Better Place Insurance Group at Better Place Insurance Group | Website | + posts

Experienced Insurance Advisor and financial planner. Graduated from Webber International University with a Bachelor of Science in marketing and a Masters in Business Administration. Skilled in Public Speaking, Team Building, Management, Marketing, Direct Sales, and Strategic planning.

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