What to Do if Your Doctor Won't Take Medicare
More physicians are refusing, so ask yours before you hit 65 and then follow these strategies if you'll be turned away
Caroline Mayer is a consumer reporter who spent 25 years working for The Washington Post. Follow her on Twitter @consumermayer
Among my friends, some of these conversations have taken on an added urgency as we near age 65, when Medicare will likely become our primary health insurance. We’ve been looking forward to that day, believing our health care costs and hassles will be minimized.
(MORE: 4 Mistakes to Avoid When Enrolling in Medicare)
The Medicare Complaint That’s Growing
But we’re learning that Medicare’s not so easy after all. There are still monthly premium payments, copays and deductibles — and not all claims are processed smoothly.
Even more distressing is the complaint I’ve been hearing over and over: Some doctors are now refusing to take Medicare patients. They’re balking at the federal health program’s mandatory, low reimbursement rates and high paperwork burdens.
For example, while nearly 80 percent of the Texas Medical Association’s doctors were taking new Medicare patients in 2000, last year fewer than 60 percent were, according to a recent PBS NewsHour report.
This is unsettling news, but I have some advice that could help if your doctor balks at taking Medicare.
Your Choices When Your Doctor Opts Out of Medicare
When doctors exit the Medicare system, their patients are basically left with two unpleasant choices: Either find another physician who accepts Medicare from what seems to be a narrowing list or continue seeing their doctor and take on responsibility for paying the entire bill. If you choose the second option, you can try negotiating a lower fee (more about that later).
How Big Is the Problem?
Medicare officials say the number of doctors who don’t accept Medicare is very small. According to their figures, only about 4 percent of U.S. doctors don’t participate and most beneficiaries (as patients are called in Medicare lingo) can see the doctors they want. Still, a 2013 annual report by the Medicare Payment Advisory Commission, an independent congressional agency, shows that 28 percent of beneficiaries seeking new primary-care physicians and specialists last year had trouble finding ones who accepted Medicare.
“We’re hearing of problems more than the statistics show,” says Joe Baker, president of the Medicare Rights Center, a nonprofit that helps Medicare beneficiaries navigate the system’s complexities.
(MORE: How to Find a New Doctor)
Baker believes there are pockets of the country, primarily in wealthier urban areas, where a growing percentage of doctors no longer take any insurance, regardless of their patients’ age.
3 Ways Doctors Deal with Medicare Patients
Before I get to my advice, let me explain the three ways doctors can choose to take on or deny patients on Medicare:
First, there are the doctors who accept assignment. That means they agree to the Medicare-approved amounts for their services.
As a patient of one of these physicians, you’ll have to pay the annual Medicare Part B deductible ($147 in 2013) and a 20 percent copay per visit, but nothing more. This is clearly the least expensive option.
Next come the non-participating doctors. To me, this term sounds like a misnomer. These physicians do accept Medicare, just not its official reimbursement amounts.
Rather, these doctors can bill patients up to 15 percent more than the official Medicare charges (some states, like New York, have a 5 percent limit). The cost over the Medicare-approved amount is called “the limiting charge.”
So if you get a $200 bill from a non-participating doctor and Medicare will pay $160, you’ll owe the $40 difference, plus the 20 percent copay.
This type of out-of-pocket cost can mount quickly if you see a doctor often, although some Medigap insurance plans will help cover the difference.
Last, there are the opt-out doctors who accept no Medicare reimbursement and put the onus on the patient to foot the entire bill, except for medical emergencies. These physicians are required to tell patients the costs of services up front and have them sign what are known as private contracts, agreeing to the opt-out method.
The Importance of Taking Precautions
To avoid the possibility that your doctor won’t accept Medicare when you hit 65, plan ahead.
When you’re in your late 50s or early 60s, ask your physician whether he or she will still treat you when you enroll in Medicare. If the answer is “no,” think about switching to a doctor who will.
(MORE: How to Prepare to Enroll in Medicare)
5 Tips if Your Doctor Won’t Take Medicare
If you’re over 65 and have discovered your doctors won’t take Medicare, here are five recommendations from Baker and other health insurance experts:
1. Consult the Physician Compare directory on Medicare’s site. This is a national list of physicians and other health care providers who accept Medicare. Before making an appointment, call to confirm the doctor is still taking new Medicare patients.
2. Ask your doctor for a referral to a physician who accepts Medicare. It could be a colleague or a protégé.
Perhaps, Baker suggests, you could see your opt-out doctor for an initial consultation then switch to a participating doctor for ongoing treatment. “I’ve done that and know others who have too,” he says.
3. If you don’t want to leave your opt-out doctor, but want to lower your costs, try negotiating the medical fees. “It’s completely appropriate for patients to ask if there’s any discount for prompt payment or cash,” says Jeffrey Rice, chief executive of The Healthcare Blue Book, a website that tracks health care prices.
Rice says many, but not all, physicians will provide discounts when their patients must pay the entire bill. It never hurts to ask.
4. Consider going to urgent care or walk-in clinics for routine medical issues. Most of these clinics accept Medicare. You might even want to use them if you’ll need minor surgery.
5. Look into a middle ground by signing up with a concierge doctor, if you can afford it. Concierge physicians agree to accept reimbursements from Medicare, but also require their patients to pay an annual fee, averaging about $1,500, for guaranteed immediate access.
Going the concierge route is expensive, since Medicare won’t pay your annual fee. The concierge charge, however, covers an extensive annual physical, with more tests than allowed by Medicare.
So this is an option to consider, if your budget permits, especially if you anticipate regular visits to your doctor and want to be sure you’ll get in anytime. That way, you know your doctor will take Medicare, and, more important, will take care of you.