Do All Doctors Accept Medicare?

Michael T. Braden, April 17, 2024 GENERAL MEDICARE

Medicare Assignment refers to a Doctor who has signed on and agrees to accept Medicare's Fee Structure and see Medicare Patients.

DO ALL DOCTORS ACCEPT MEDICARE, AND WHAT IS MEDICARE ASSIGNMENT?

What do we mean by Do All Doctors Accept Medicare? The Term "Accepts Medicare" refers to Doctors who have signed an agreement with the Government to see and treat patients, using the national Medicare Fee Schedule for the rates they charge for a given appointment, treatment, or service.

No, not all doctors in America accept Medicare. A few do not take it, but the overwhelming majority of physicians and other Healthcare professionals accept Medicare. However, there are many instances in which a Doctor Accepts Medicare but does not belong to any Medicare Advantage network.

Did you know that there are more than 1,000,000 Physicians in the USA? And, about 9.46 Doctors out of 10 accept Medicare Assignments. The largest group of Healthcare Professionals who do not accept Medicare are Psychologists, Pediatricians, and Psychiatrists.

MORE FACTS AND INFORMATION CONCERNING DOCTORS AND MEDICARE

According to the Kaiser Family Foundation, the states with the lowest percentages of physicians accepting new Medicare patients include Utah and Oregon (79%), followed by California, Nevada, Washington, Alaska, Maine, and Maryland (80-82%), and followed by Montana, New York, and Connecticut, at between 83% and 84%. The data suggest that the percentage is lower in states with a Medicare Birthday Rule.

MORE PROOF THAT DOCTORS AND PHYSICIANS ARE NOT FOND OF MEDICARE ADVANTAGE PLANS

If your doctor, hospital, clinic, specialist, or other healthcare provider accepts Medicare Parts A and B, they must accept any Medicare Supplement plan from any insurance company. That is because it is legally required. Doctors are not required to accept Medicare Advantage plans or Medicare Part C patients/members. The latest nationwide estimates indicate that only 46% of doctors in the United States receive any Medicare Advantage plans. And, many of those only take 1-4 plans.

Doctors do not favor Medicare Advantage plans, as evidenced by the percentage of doctors who report this year after year. Just over 20% of all Medicare Advantage (Medicare Part) plans have a physician/provider network comprising 70% or more of the available licensed doctors in their areas. 43% of Medicare Advantage plans have networks that include only 30% to 69% of the total number of licensed physicians in the places where the plans operate. A little more than one in three Medicare Advantage plans have networks that include fewer than 30% of all available licensed physicians in the areas where their plans are available—Area physicians who accept Original Medicare. A complete 35% of Advantage plans have networks limited to less than 30% of doctors who accept Medicare in their area of coverage.

Doctors dislike the pressure they receive from Medicare Advantage Plans to lower their fees continually, and they also do not like telling Medicare Beneficiaries that they will need multiple referrals for a procedure they believe is Medically Necessary. They are frustrated by hearing complaints from Members.

Can Doctors Refuse To Accept Medicare Advantage Plans, even if they accept Medicare?

EYE-OPENING STATISTICS

Medicare enrollees aged 65 and older are the fastest-growing demographic in the U.S. 17% of the U.S. population was age 65 or older as of 2020, and that share is projected to exceed 22% in 2039.

Just 3 years ago, 5 million people aged 65 or older were living below the Federal Poverty Level in the US. And, if that isn't startling enough, an additional 2.6 million people considered themselves to be nearly broke or almost poor. Combined, that is virtually the same number of people who live in the entire state of Maine! These are the demographic groups most likely to enroll in a Medicare Advantage plan because they cannot afford the premiums associated with a Medicare Supplement (Medigap) plan.

HOW OFTEN DO DOCTORS DECIDE NOT TO ACCEPT MEDICARE?

In 1990, only about 3% of doctors opted out of Medicare, but recent reports indicate a decrease in that number. In 2020, approximately 1% of doctors opted out. Factors such as hospitals acquiring medical practices and new doctors preferring to join medical groups (which involve them in Medicare) contribute to this trend.

Medicare-age patients are the most significant and fastest-growing demographic of medical patients. In addition, Original Medicare and Medigap plans pay within days or weeks of receiving a bill. Months faster than the average turnaround of private health insurance or Advantage plans.

In all states except Alaska, Colorado, and Wyoming, the percentage of physicians who have opted out of the Medicare program is less than 2%. Do all physicians accept Medicare? No, but almost 94% of ALL doctors accept Medicare. The biggest group of Doctors who historically do not accept Medicare are Pediatricians, Naturopathic doctors, Homeopathic Doctors, psychologists, and Psychiatrists.

IS IT HARDER TO FIND A DOCTOR ACCEPTING NEW MEDICARE PATIENTS RIGHT NOW?

According to KFF, an independent source for health policy research, polling, and news, most non-pediatric office-based physicians accept new Medicare beneficiaries and new private insurance patients.

An analysis of 2019 National Electronic Health Records Survey (NEHRS) data found that 89% of physicians accepted new Medicare patients that year. Similarly, 91% of physicians accepted new patients with private insurance.

Among primary care physicians, acceptance rates were slightly lower but still comparable: 83% accepted new Medicare patients versus 86% accepted new private insurance patients.

The analysis also revealed that the percentage of non-pediatric office-based physicians accepting new Medicare patients remained consistent between 2011 (88%) and 2019.

If you need Medicaid services, however, you may have more trouble finding a primary care doctor who accepts your insurance. Only 45% of primary care physicians accept new Medicaid patients, according to KFF. Nearly one in every three Primary Care Physicians in the United States currently are not accepting "new" Medicaid Beneficiaries.

WHY DO DOCTORS ACCEPT MEDICARE IF IT PAYS THEM LESS?

There are ongoing discussions about the adequacy of Medicare payments to physicians and concerns about potential access issues if Medicare rates were implemented.

However, cash flow is key to a medical office's survival. Unlike other types of health insurance, Original Medicare pays within 2 weeks of receiving a bill. Most Medigap plans pay over 85% of claims within 48%. That generates positive cash flow, which is key to any medical office's sustainability.

Medical providers are not required to accept Medicare. The decision to accept or not accept Medicare is up to each doctor or healthcare provider.

WHERE CAN YOU GO TO FIND DOCTORS WHO ARE CURRENTLY ACCEPTING NEW MEDICARE PATIENTS?

We are often asked by clients what the best practices are to find physicians who 1) Accept Medicare and 2) Are currently accepting new patients. Below are some of our top recommendations.

To find a doctor who accepts Medicare, you can:

• Here is the link to a free Physician Finder Search Tool on the Medicare Website: https://www.medicare.gov/care-compare/

•  If you have had any doctors in the past who you liked, the best course of action is to call their office and let them know you are either a current or former patient, and you are about to enroll in Medicare, and ask them if their office accepts Medicare.

•  Consult your primary care physician, who may be able to recommend other doctors who accept Medicare patients.

•  Ask friends who may be on Medicare whether their doctors are accepting new patients.

•  If you have a Medicare Advantage plan, use the Provider tool on the insurance company's website. Remember, however, that fewer than half of doctors licensed in the United States accept Medicare Advantage; the number is approximately 45%. Once you find a doctor who says they are accepting new patients, call the doctor's office to verify that A) The Doctor is still associated with your specific Medicare Advantage plan, and B) they are accepting new patients.

•  Hopefully, you worked with or are currently working with a licensed, independent Medicare Broker or Medicare Agent. We encourage you to ask them for help with anything, whenever you need it, including assistance with finding doctors. Brokers will always make time to talk and help you as much as they can.

WHAT DOES IT MEAN TO YOU IF A DOCTOR ACCEPTS MEDICARE ASSIGNMENTS?

When a medical professional chooses to work with Medicare, they have two options for annual contracts: Participating Provider or Non-Participating Provider.

A Participating Provider agrees to accept the Medicare-approved rate for services and bills Medicare directly, not the patient. This agreement is known as Medicare assignment. When a doctor agrees with an assignment, they are referred to as a "Participating Provider".

By law, doctors and physicians who accept Medicare Assignments are not permitted to charge anyone with Part B Excess Fees/Charges.

A significant advantage for physicians who accept Medicare assignments is that Medicare handles the entire Billing Process. For Physicians who accept Medicare, the physician only needs to submit a Medicare claim. Medicare then sends payment to the Physician, and they automatically send a notice to the Medicare beneficiary's Medicare Supplement/Medigap plan to pay their portion. Medicare electronically communicates with every Medicare Supplement/Medigap Insurer and provides them with all the instructions they need to follow. Including who to pay, when to pay them, and who the payment is on behalf of.

IS IT A BIG PROBLEM IF MY DOCTOR DOES NOT ACCEPT MEDICARE ASSIGNMENTS?

When a physician intends to bill the patient more than the Medicare assignment rate, they may elect to contract as a Non-Participating Provider with Medicare. Being a non-participating doctor in the Medicare program means they are not required to accept assignments, and are authorized to charge Medicare Part B Excess Fees if they choose to do so. Many surveys suggest that less than 25% of Doctors actually charge the additional 15%. This is obviously not a good look and is one of those situations where nobody wins.

This is a less-than-ideal scenario for all the parties involved. So here is what Medicare has done to incentivize doctors to accept Medicare's Fee Schedule:

1. To begin with, Medicare will reimburse non-participating providers 5% less than they pay participating providers. Then, non-participating providers may bill only up to 15% more than the Medicare reimbursement rate. Ultimately, the physician will receive only 9.25% more than by accepting a Medicare assignment.

2. A significant benefit for every Medicare Provider is that Medicare handles and coordinates all billing. This saves a Doctor's Office many hours a month and a considerable amount of money every year. In fact, this is one of he significant "Benefits" of Accepting Medicare.

3. If a Physician determines that it is not in their best interest to "Accept Medicare," they are labeled a non-participating provider. The consequence of being a Non-Participating medical provider is that Medicare will not handle billing as a one-stop process. Although the doctor’s office will still be required to submit a bill to Medicare, Medicare will not forward the bill to Medigap plans. Since the doctor lacks a contract with Medigap plans, they cannot bill them either. Instead, they usually require patients to pay for services up front and then seek reimbursement directly from their supplemental insurance company. This is the worst-case scenario for the Medicare Beneficiary because they typically must complete two separate CMS Form 1940s, one for Medicare and one for the Medicare Supplement Carrier, to be reimbursed. Accordingly, we strongly encourage each of our clients to see Doctors, Physicians, Clinics, and Hospitals that accept Medicare Assignments.

4. A physician's office must notify you ahead of time or display a conspicuous sign that alerts you to a potential excess charge.

DO ALL DOCTORS ACCEPT MEDIGAP/MEDICARE SUPPLEMENT PLANS?

If a doctor accepts Original Medicare and Medicare assignment, they must take any Medigap plan you have, from any insurance company. Note that they don’t bill the Medigap plan; Medicare does.

According to a Kaiser Family Foundation report, Medicare enrollees without supplemental insurance face challenges finding physicians who accept Medicare without a supplemental plan. It is recommended that these patients consider purchasing Medicare supplement insurance.

WHAT HAPPENS WITH MEDICARE ASSIGNMENT IF I HAVE A MEDICARE PART C PLAN?

Not all doctors accept Medicare Advantage plans. Part C Advantage plans have networks of doctors and healthcare providers who have agreed to take the plan’s terms and conditions. These networks vary between different Part C plans.

ARE THERE MINIMUM NUMBERS OF DOCTORS THAT MEDICARE ADVANTAGE PLANS NEED TO HAVE IN THEIR NETWORKS?

One significant disadvantage of Medicare Part C is that its networks are often small, resulting in minimal coverage in some regions of the country. The weakness of Advantage Plans is their limited network.

A little over one in every five Medicare Advantage Plans has a network that consists of 70% of doctors who accept Medicare in their area. 43% of Advantage plans have networks that include only 30% to 69% of area physicians who accept Original Medicare. A complete 35% of Advantage plans have networks limited to less than 30% of doctors who accept Medicare in their area of coverage. When you have a Medicare Advantage plan, you need to review the plan’s provider directory or contact the plan directly to verify if your preferred doctors and healthcare providers are in-network. Seeing an in-network provider typically results in lower out-of-pocket costs and ensures that the services are covered by your Advantage plan for a Medicare-approved amount.

HOW MANY DOCTORS IN THE UNITED STATES ACCEPT MEDICARE ADVANTAGE PLANS?

In surveys conducted by the well-known Kaiser Family Foundation (KFF), less than 50% of doctors who are contracted with Medicare accept some Advantage plans (aka Medicare Advantage). Even then, they may not receive your plan. Doctors' networks vary by Medicare plan and may change annually.

Medicare enrollees without supplemental insurance face challenges in finding Physicians who accept Medicare without a supplemental plan. It is recommended that these patients consider purchasing Medicare supplement insurance.

WHY DO SO MANY DOCTORS NOT ACCEPT MEDICARE ADVANTAGE PLANS?

Doctors do not usually accept all Advantage plans, nor are they required to do so. These Medicare plans have their own networks of doctors and healthcare providers who have agreed to accept the terms and conditions of specific plans. Provider networks and health coverage can vary across Advantage plans.

Unlike Original Medicare, Part C plans enter into separate annual contracts with physicians and healthcare networks for medical services. In many cases, Physicians generally earn less from Medicare Advantage plans than they would from Original Medicare. However, they typically reduce their Marketing and Advertising budgets because of the potential business they may receive from MA plans.

Most established Doctors do not accept Medicare Advantage plans. They do not want to rely on an Insurance company to dictate their terms, and, frankly, they are not accepting of the constant low-ball tactics that MA plans to impose on them, and they know all the horror stories they hear directly from their patients.

WRAPPING THINGS UP

I hope you enjoyed this article and that you have a clear understanding of what it means for a physician to "Accept" Medicare Assignment.

If you have any questions about Medicare, please text, email, or call us at any time that is convenient for you.