Often people say that a certain doctor or other medical provider “takes Medicare,” but it’s not an accurate description of a doctor’s contract status with Medicare. There are actually three distinct categories of provider when it comes to Medicare, each with their own potential costs and limitations for clients.
– A participating provider is one that agrees to accept assignment of Medicare benefits and can charge no more than the Medicare fee schedule amount for any services.
– Clients will not be liable for excess charges, even without a Medicare Supplement plan that would cover them.
– 96% of providers who offer services that Medicare would cover are participating providers.
– Non-participating providers can choose to accept Medicare assignment on a per-service basis. If they accept assignment for a particular service, they can bill Medicare directly and the member will pay no more than their usual cost-sharing.
– If they choose not to accept assignment for a service, the client is liable for excess charges and may need to pay up front and wait for reimbursement from Medicare for the covered amount. Excess charges are limited to 9.25% of the Medicare approved amount for a service, in addition to whatever the member’s usual cost-sharing would be. You can check our post on excess charges for more details.
– Providers who have opted out cannot accept reimbursement from Medicare and must enter into a private agreement with their patients.
– Patients will sign a contract with the provider agreeing to that provider’s fees and policies.
– Patients who see a psychiatrist should be especially aware of the limitations for providers who have opted out. While only 4% of providers nationwide have opted out, 42% of those are psychiatrists.
– Medicare Supplement plans will not pay anything towards services from a provider who has opted out.
Knowing the difference between participating, non-participating, and opted out providers can save your clients money and headaches!