Medicare is a federal health insurance program for those who are 65 years old or older and for young adults with disabilities. With Medicare, you may not be charged more than the Medicare-approved amount for your healthcare services. If your healthcare provider refuses to take Medicare, you may have to pay the entire medical bill. This may be concerning, as it could take a financial toll on an individual’s finances.
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When Your Doctor Doesn’t Accept Medicare
When a doctor no longer takes or refuses Medicare patients, they are called opt-out doctors. Opt-out doctors do not accept Medicare reimbursements and may have the patient pay for the entire bill. Doctors who do not accept Medicare must tell their patients the cost of services upfront. If the patient agrees with the cost, they must sign a private contract that states they have agreed to the opt-out method.
Some doctors may offer a discount for their established patients. Often, they may have payment plans you choose to do instead of paying the entire bill at once. If you have any questions, you may call your doctor’s office to clarify if they offer any discounts or payment plans.
Why Do Some Doctors Not Accept Medicare?
Some doctors do not accept Medicare due to Medicare’s low reimbursement rates of about 30-to-50% from Medicare patients.
In not accepting patients with Medicare, doctors may have more flexibility to charge higher fees for their practice. In doing so, they may continue to keep their practice in business, hire more people, and upgrade to more advanced equipment.
Doctors may also opt out of Medicare because they may prefer to be paid directly by their patients instead of the insurer. If the payments are through the patient themselves, this may limit any source of the administrative burden that the healthcare provider has.
Administrative burden may consist of collecting and processing paperwork, making sure the patient’s health is compliant with the insurer, and filing a report to get reimbursed. These tasks may become a burden to doctors who do not have many employees, as they could be seeing more patients instead.
How Common Is It For Doctors Not To Accept Medicare?
Psychiatrists account for the largest share of opt-out providers in comparison to physicians who practice family medicine, internal medicine, and OB/GYN.
Although less than 2% of healthcare providers in each state have opted out of Medicare, this has been a growing issue in the healthcare industry. Due to increased inflation in the United States, reimbursements from Medicare may not be able to uphold a doctor’s practice. Even if a healthcare facility accepts Medicare, it may refuse to take new patients with Medicare. Doing so may restrict healthcare access to Medicare beneficiaries.
Options For When A Doctor Has Opted Out of Medicare
If your doctor has opted out of Medicare, there are options you may take to ensure you still have access to healthcare year-round.
Ask Current Doctor For Recommendations
If a doctor is opting out of Medicare, they may have prepared for this transition for a while. That being said, your doctor may already have a list of recommendations that they would refer you to. Since they have worked with you and know your current health conditions, they may have specific doctors in mind for you.
Review The Medicare Directory
Medicare’s directory has a list of current doctors that still accept Medicare, and consists of doctors from all over the nation. If you have found a doctor that you want to go see from the directory, you may call their office to make sure they accept Medicare.
Consider Urgent Care or Walk-in Clinics
The majority of urgent care or walk-in clinics accept Medicare. These clinics accept anyone in a health emergency, non-life threatening illnesses and injuries, and lab tests. Walk-in clinics may serve as a patient’s primary care. Instead of going to see a doctor for a flu shot, for example, they may visit their walk-in clinic instead.
Ask For Available Discounts
Since opt-out doctors must tell their patients the cost upfront, you may ask if there’s a reduced price for an established patient. If you forget to ask before a procedure, you may call the healthcare provider’s billing office that’s shown on your medical bill. You may ask if you qualify for any financial assistance program or charity care. Oftentimes, the billing department may reduce your bill depending on your income level.
If your doctor chooses to opt-out of Medicare, you may pay out-of-pocket instead. When paying out-of-pocket, you may request a discount or see if your doctor offers payment plans.
Paying out-of-pocket may be beneficial for individuals who do not go to the doctor often. If you find yourself going to the doctor more than twice a year, it may be best to find a doctor that accepts Medicare.
Medicare Advantage Plans
If you’re on a Medicare Advantage plan, you may only go see doctors that are in your plan’s network. Be prepared to pay more out-of-pocket if you choose to go see doctors outside of your plan.
Bear in mind that if a doctor has opted out of Medicare, it also means they have opted out of Medicare Advantage plans. However, doctors who are in contract to be in-network for Medicare Advantage plans must stay in-network for the length of their contract. This means that you may continue seeing your in-network doctor until they opt out of their contract.