As people consider Medicare for their medical coverage after 65, or even how to manage their care once they are on Medicare, they often question how to find doctors that will treat them — doctors that “take Medicare.” This is one of the key questions clients ask me about Medicare all the time.
Providers can be grouped this way with regards to their participation in Medicare:: (1) doctors that do not accept Medicare payments at all; (2) doctors that take Medicare assignment; and (3) doctors that take Medicare but reserve the right to pass along excess charges to the patient.
In the first instance, the doctor does not bill Medicare nor do they participate in any network associated with a Medicare Advantage network. They are free to charge a patient anything they desire and will look solely to the patient for compensation.’
In the second case, a doctor signs a 2-year agreement with Medicare to bill them for services provided for a beneficiary under Medicare. This agreement also stipulates that the amount Medicare pays them (the reimbursement) is the sole amount the doctors will receive for compensation for that care.
In the last instance, a doctor agrees to bill Medicare but reserves the right to bill “excess charges” directly to the beneficiary. These charges can be up to 15% above the amounts reimbursed by Medicare. If a Medicare beneficiary has a Medicare Supplement (Medigap), only Plans F and G pick up these excess charges. It should be noted, that while there is a 15% ceiling on excess charges for each episode of treatment, there is no out-of-pocket maximum for the beneficiary for aggregate excess charges.
Providers participating in a Medicare Advantage plan are paid for a beneficiary’s Medicare charges through a contract they have with an insurance company. In such cases, it is that contract that defines how much the provider is paid for each episode and type of care.
So….people want to know how to find doctors that “take Medicare.” In the case of a Medicare Advantage plan, they will select a doctor from that plan’s network.
If someone has a Medigap plan, they need to ask their doctor if they “bill Medicare.” There are no networks with a Medigap plan (although in some states, Medicare Select plans exist that do employ networks). This means that the doctor “takes Medicare” because in actual fact the doctor will bill Medicare for the treatment they provide. Once Medicare has paid their share, Medicare will electronically notify the Medigap plan, which in turn will pay whatever cost sharing amounts are stipulated under the plan the beneficiary has. In the case of a Plan F, the Medigap company will reimburse cost shares under all Medicare benefit categories.
The controversy that periodically erupts over doctors refusing to see Medicare patients is rooted in the matter of Medicare cost reimbursement for physicians. We will deal with that issue in a future blog.-->