Do All Doctors Accept Medicare?

The good news is that most healthcare providers do accept Medicare. In October 2020, KFF reported that “the vast majority (97%) of physicians and practitioners billing Medicare are participating providers.”

Health care providers can choose to work with Medicare in different ways or not at all, and their choices carry over into how much Medicare beneficiaries can be charged.

Upon eligibility for Original Medicare, there are two tracks you can follow for your health insurance. One is to get your Medicare benefits from Original Medicare with the option of adding a Medicare Supplement plan (Medigap). The alternative is to get your Medicare Part A and Medicare Part B benefits through Medicare Advantage. One of the essential distinctions between Medicare Advantage and Medigap is the freedom to choose doctors and other healthcare providers for covered services without jeopardizing your benefits. But if you have Medicare coverage, not all doctors will welcome you as a patient regardless of which Medicare health plan you have.

Not All Doctors Accept Medicare – Here’s Why That Matters

Part A is hospital insurance for home health care, hospice care, and hospital inpatient costs. Under Part B, Medicare covers outpatient care, home health services, physician services, mental health services, and durable medical equipment.

Medicare Advantage plans, which encompass Part A and Part B, and often Medicare Part D (prescription drug plan), use provider networks. HMO insurance plans are generally more restrictive than PPOs. An HMO typically requires exclusive use of the plan’s network. With a PPO, the insurance company usually provides coverage for out-of-network providers but with reduced benefits. Enrollment in Original Medicare and Medicare Supplement Insurance does not confine you to a provider network. The caveat is that you must use a Medicare provider to get benefits for covered Medicare-costs.

The following terminology describes how your healthcare provider’s relationship with Medicare impacts your benefits:

  • Assignment: Medicare assignment is an agreement between your provider and Medicare whereby the provider accepts the Medicare-approved amount as payment in full, notwithstanding coinsurance and deductibles that fall under patient responsibility.
  • Participating: Participating doctors have contractual agreements with Medicare to accept assignment and submit claims directly to Medicare without charging you.
  • Non-participating: Non-participating providers accept new Medicare patients but choose to accept assignment on a case-by-case basis. If your provider does not accept assignment, the doctor can send you a balance bill, though this practice is prohibited in some states.
  • Limiting charge: Non-participating provider charges are capped at 15% above the Medicare-approved amount, not including your copayment, coinsurance, and deductibles. These charges are called excess charges, and the practice is called balance billing.
  • Opt-out: Providers who choose not to register with the Medicare program can set payment terms directly with the patient through a private contract. There is no limit to what an opt-out provider can charge, and the entire bill is the patient’s responsibility. Neither Medicare nor Medigap will pay for covered medical equipment or services rendered by opt-out providers, though some emergencies may qualify as exceptions.

Why Some Doctors May Not Accept Medicare

A doctor’s decision not to accept a Medicare health plan may be primarily attributed to administrative requirements, the lag between the service date and reimbursement, and Medicare payments reduced according to Medicare’s fee schedule. According to Kaiser Health News (KHN), many primary care physicians argue that Medicare “doesn’t reimburse them adequately and requires too much paperwork to get paid.”

As for specialists, Kaiser Family Foundation (KFF) pointed out that the following medical fields had the highest opt-out rates, based on 2020 published data from the Centers for Medicare and Medicaid Services (CMS):

  • Psychiatry: 7.2%
  • Plastic and reconstructive surgery: 3.6%
  • Neurology: 2.8%

How To Find a Doctor Who Accepts Medicare

Since you are paying premiums for Part B, it makes sense to use doctors who accept Medicare so that you can receive benefits from the Medicare program.

Here are suggestions to help you find doctors who accept Medicare:

  • Medicare offers an online Physician Compare tool to find and compare Medicare doctors based on zip code.
  • You can check if your doctor has not registered with Medicare by searching the opt-out database accessible through the Medicare website.
  • Contact the physician’s office, and ask to speak to the insurance specialist to confirm if the doctor is a participating provider. Participating providers must accept assignment.
  • Sometimes, the best recommendations are word-of-mouth. Ask friends and family members for recommendations of doctors who accept Medicare, or use your local neighborhood app. Always check with the doctor’s office when you call to schedule the appointment.

What To Do if a Doctor Does Not Accept Medicare

If your doctor has dropped out of the Medicare insurance program, or you found an opt-out doctor you would like to engage, you have these options:

  • Ask your doctor to work with you on payment terms, and sign a written agreement.
  • Don’t be too shy to inquire about a discount because it’s not uncommon for doctors to charge private-pay patients a different amount than patients with private insurance.
  • If there are Medicare-participating urgent care centers in your area, consider using their services for non-emergency primary care.
  • Work with licensed insurance agents to guide you in your search for qualified Medicare doctors who are accepting new Medicare patients.

The good news is that most healthcare providers do accept Medicare. In October 2020, KFF reported that “the vast majority (97%) of physicians and practitioners billing Medicare are participating providers.”