Want Medicare to Pay for Services? Choose the Right Doctor
Mar 28, 2016
You’ve got Medicare and a supplement. You think you’re in good shape and then comes a big bill. Here are two examples.
Sandra’s situation: “The ophthalmologist’s charge for cataract surgery was $8,000. He wanted $2,500 up front and now I got a bill for the rest."
Tom’s story: “I needed surgery and went to a specialist. He sent a bill for $11,000. Now, he tells me I have to pay that and I can’t submit it to Medicare.”
Sandra and Tom are justifiably upset with the costs. They pay premiums for their coverage but still have significant out-of-their pocket costs. What happened? In both cases, Medicare would have provided better payment had these beneficiaries selected doctors who accepted Medicare assignment. It’s very possible, given the available Medigap benefits each has, that there would have been no out-of-pocket cost.
Here’s what you need to know about the types of physician billing arrangements with Medicare.
- Physicians who accept assignment: These doctors agree to take Medicare’s payment for services. They can bill only the allowed Medicare amounts, such as 20% coinsurance. Any Medigap policy will cover this, leaving no bill for the beneficiary. These doctors do not have to see every Medicare patient, but when they do, they accept assignment.
- Non-participating physicians: On a case-by-case basis, these doctors decide whether or not to accept assignment. If they do accept assignment, the beneficiary gets the most benefit. If they do not take assignment, they will submit a claim to Medicare on the beneficiary’s behalf and are permitted to add up to an additional 15% to the bill. This is known as Part B excess charges. Medicare will pay the beneficiary, who, in turn, as to pay the patient. Those who opted for this optional Medigap benefit will not see a bill.
- Physicians who have opted out: Not only do these doctors not accept assignment but they have opted out of Medicare completely. They do not bill Medicare and must establish a contract with the patient. Neither the physician nor the beneficiary can bill or receive payment from Medicare. (This is the type of physician that Sandy and Tom had.)
So, the next time you see a new physician, check his or her status at https://www.medicare.gov/physiciancompare/search.html.
PS This information applies to beneficiaries who have selected Original Medicare with a Medigap policy. Those who elected Medicare Advantage must pay attention to networks.