How to Find a Doctor Who Will Take Your Family Member as a Patient

 

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.

 

Older Woman With Doctor

How the Medicare Reimbursement System Works

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:

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A Doctor's Options

The doctor does not have to accept assignment. The doctor has four choices. He or she may:

What does this mean

Accepting Assignment
If the doctor accepts assignment, the patient will pay an annual Medicare deductible and the 20 percent of the cost of the service that Medicare does not pay (Medicare pays 80 percent of the cost they have agreed is appropriate for the service). For example:

Doctor Charge $200
Medicare Approved Rate $150
Medicare Reimbursement
(80% of approved rate)		 $120
Patient's 20%
(assuming deductible already met)		 $30
Total Payment to Doctor Through Medicare Including Patient's Portion $120 + $30 = $150
Additional Patient Responsibility $0
Total Charge to Patient $30

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Does Not Accept Assignment
If the doctor chooses to charge a higher amount (i.e. does not accept assignment), the patient will pay an annual Medicare deductible, the 20 percent of the cost of the service that Medicare does not pay (Medicare pays 80 percent of the cost they have agreed is appropriate for the service), and the difference between the total charge by the doctor less the amount of the Medicare reimbursement and the 20 percent paid by the patient. In other words, a doctor who does not accept assignment expects to be paid the total charge for the service. Whatever Medicare does not pay, the patient is responsible for paying. For example:

Doctor Charge $200
Medicare Approved Rate $150
Medicare Reimbursement
(80% of approved rate)		 $120
Patient's 20%
(assuming deductible already met)		 $30
Total Payment to Doctor Through Medicare Including Patient's Portion $120 + $30 = $150
Difference Between Total Charge and Medicare Reimbursement $200 - $150 = $50
Additional Patient Responsibility $50
Total Charge to Patient $80

 

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).

Limiting Charge
If assignment isn't accepted, a doctor may charge more than the Medicare-approved amount. For most services, there is a limit on the amount over the Medicare-approved amount the doctor can bill you. The highest amount of money a patient can be charged for a Medicare covered service by a doctor who doesn't accept assignment is called the limiting charge. The limiting charge is 15% over Medicare’s approved amount. The limiting charge applies only to certain services and doesn't’t apply to supplies and equipment. Be sure to ask. And, please note that if you sign a private contract with a physician who does not participate in Medicare as a participating physician, that physician is not subject to the limiting charge.

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Accept Assignment on a Case-by-Case Basis
Another option that a doctor has is to accept assignment on a case-by-case basis. Looking at examples above, the patient would be charged exactly as the example for accepting assignment. The best way to make this choice happen is to talk directly to the doctor and convince him or her to take your family member on as a patient, accepting assignment in this particular case.

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Doctor Does Not Participate with Medicare in Any Way
Doctors are required to submit claims for reimbursement to Medicare. Patients are not allowed to submit claims. A doctor, hospital, or supplier may choose not to accept Medicare as part of the payment. Most likely, that decision would be based on the amount of paperwork and staff time involved. If a patient chooses to use a doctor, hospital, or supplier that does not accept Medicare, Medicare will not pay for the service. In other words, Medicare will not reimburse the patient. No paperwork will be sent by the doctor and Medicare does not allow patients to submit claims.

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":

  • Medicare health plans won’t pay any amount for the services received from this doctor.
  • The patient will have to pay whatever this doctor or provider charges for the services received.
  • Medicare’s limiting charge won’t apply.
  • No claim will be submitted to Medicare, and Medicare won’t pay if one is submitted.
  • Any Medigap policy, if the patient has one, won’t pay anything for this service. Call the Medigap insurance company before getting the service if there are any questions.
  • Many other insurance plans won’t pay for the service either.
  • The doctor must tell the patient whether Medicare would pay for the service if the patient gets the service from another doctor who participates in Medicare.
  • The doctor must tell the patient if he or she has been excluded from the Medicare program.

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.

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What Can You Do To Find a Doctor?

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.

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Medicare Participating Physician Directory        (scroll down to find the link)
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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.

 

NCIf 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.

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What About Prescription Drugs and Supplies?

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)
  • Optometry/Opticians

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.

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Personalized Assistance

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.

 

NCIn North Carolina

 

 

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