As a caregiver, you may find circumstances where your family member needs the care of a doctor that he or she has not seen before. If your family member is on Medicare, they may experience difficulty finding a doctor who will treat them. The reason may be that the doctor does not want to accept the amount of compensation for medical services that Medicare will agree to pay.
Medicare is divided into two parts, Part A (typically pays for inpatient hospital expenses) and Part B (typically pays for outpatient healthcare expenses, including doctor fees).
If you are having trouble finding a doctor who will treat your older family member, Medicare Part B may be involved.
Medicare determines what level of payment it considers appropriate for specific services. These are called "Medicare approved charges".
Doctors may agree to limit what they charge patients to the Medicare-approved amount for the services they provide, or they may charge a higher amount. Those who do agree to accept Medicare's rates for services are said to "accept assignment". A doctor may choose to charge a higher amount than the Medicare-approved amount for service. They do not accept assignment. Both doctors would be considered a "participating physician" in the Medicare program. However, if a doctor takes you on as a patient and has you sign a contract that says that they will not file for Medicare for you (you are not allowed to do it yourself, per Medicare), they are not considered a "participating physician".
Medicare also keeps a list of Medicare-approved services - ones for which they will pay. If a doctor is a "participating physician" and "accepts assignment", Medicare will pay 80 percent of the Medicare-approved amount for the Medicare-approved service(s) provided. The patient pays an annual deductible and is responsible for the remaining 20 percent. This can be paid through private insurance, out-of-pocket, or other programs.
For more detailed information about Medicare:
The doctor does not have to accept assignment. The doctor has four choices. He or she may:
- accept assignment
- choose to charge a higher amount
- offer assignment on a case-by-case basis
- not participate with Medicare in any way
What does this mean
Does Not Accept Assignment
In addition, doctors who do not accept assignment may make a patient pay the entire charge at the time of service. A doctor must submit the patient claim to Medicare. The patient is not allowed to. The patient would then have to wait to be reimbursed for the 80 percent of the Medicare-approved amount (less any owed annual Medicare deductible).
Accept Assignment on a Case-by-Case
Doctor Does Not Participate
with Medicare in Any Way
When a doctor does not want to provide services through the Medicare program, a written agreement between the patient and the doctor must be signed to ensure that the patient understands that the total charge for the service will be his or her responsibility. This "private contract" only applies to the services the patient gets from the doctor (such as a physician, dentist, podiatrist, or optometrist) who asked that the private contract be signed. A patient can’t be asked to sign a private contract in an emergency situation or when urgently needed care is necessary.
If a patient signs a "private contract":
Before signing a private contract, talk with someone from the State Health Insurance Assistance Program in your older family member's state. It could save your family money.
Medicare offers an online service to help patients find participating doctors. You enter either a zip code or the county and state, identify the type service needed and Medicare lists the physicians, location, contact information and the opportunity to see the physician's credentials. Please note that there is no way to determine when the list was last updated. Consequently, it would be best to use the list as a starting point and always ask the doctor if they participate in Medicare and if they accept assignment.
Each state has a "state approved carrier" for Medicare. They are another resource for patients to get current lists of participating physicians and suppliers for Medicare. Contact the State Health Insurance Information Program where your older family member lives to find out the carrier for that state.
|Locate My State Health Insurance Information Program|
|Locate My State Health Insurance Information Program|
If you live in North Carolina these are your carriers:
Note: CIGNA (Medicare Part B) uses the Medicare website list of participating physicians. Their "MEDPARD" information is the Medicare official list.
If you need assistance, contact your Area Agency on Aging. They know of this issue and may know what doctors in the area or surrounding area are willing to accept assignment.
Suppliers of healthcare equipment and items also have the choice to "accept assignment" just as doctors do.
A supplier may provide items such as:
- Durable Medical Equipment (wheelchairs, walkers, oxygen)
- Prosthetics (artificial limb replacements or dentures)
- Orthotics (mechanical devices used to assist in mobility or supplement the joints and limbs)
A supplier may also be:
- Pharmacy (prescription drugs)
If the patient goes to a pharmacy, optician, or supplier that does not accept assignment, Medicare will not pay for any of the cost. The patient will be responsible for the entire bill for any drugs or supplies.
Always ask if a provider of services or supplies accepts assignment before agreeing to the purchase or the delivery of the service.
Medicare offers a "Supplier Directory" online or call 1-800-MEDICARE (1-800-633-4227) to find a supplier in a particular area. Please be aware that a patient does not know when the list is updated. Use any list as a starting point, but always be sure to ask if a supplier accepts assignment.
Each state has a "state approved carrier" for Medicare. They are another resource for patients to get current lists of participating physicians and suppliers for Medicare. Contact the State Health Insurance Information Program in the state where your older family member lives to find out the carrier for that state. They also have a vast array of knowledge about Medicare and the various supplemental policies.
In North Carolina
1-800-443-9354 or 919-807-6900