What To Do if your Doctor Won’t Bill Medicare

Most doctors accept “assignment” from Medicare patients. That means they agree to take what Medicare pays for a given treatment, procedure, or Medicare service, and not bill you beyond that. 

But many doctors won’t take Medicare at all. That’s because the reimbursement that Medicare pays to providers is notoriously low, and has not kept up with inflation. Medicare also has onerous billing processes, and imposes numerous other restrictions and requirements on providers.

That doesn’t necessarily mean you can’t get treatment from your preferred physician. Many times, there are workarounds that will enable you to receive the care you want and need while still benefiting from your Medicare coverage.

Is Your Doctor a “Non-Participating Provider?”

A non-participating provider is a doctor who has not fully signed on with Medicare, but is willing to take individual patients.

Usually, these doctors don’t participate because they don’t want to take the reduced Medicare reimbursement rate. But in most states, the law allows them to charge up to 15% more than the Medicare reimbursement rate. That means Medicare will pay its portion of covered services, and you will be responsible for paying up to an additional 15%.

In this case, you can receive treatment under Medicare.

For Medigap Policy holders

If you have a Medigap Plan C, F or G, your Medigap plan will cover the excess charges, as well as any deductibles or copays under Medicare A and B.

Medigap Plans C and F are closed to new enrollees. But Medigap Plan G covers all out-of-pocket Medicare costs, including physician’s excess charges, once you meet the annual Part B deductible, which is just $216 as of 2023. If you want to enroll in Plan G, contact your Personal Benefits Manager.

For Medi-Share 65+ Healthsharing Plan Members

If you are a member of Medi-Share 65+, a cost-saving medical cost-sharing plan specifically designed for Medicare beneficiaries, you will be responsible for the first $500 in out-of-pocket costs per household for services that fall under Medicare Part A and B auspices. The plan will share out of pocket costs above that.

In either case, you should present your Medigap or Medi-Share 65+ card, and be prepared to pay your portion of Medicare Part A and B deductibles and copays when you receive treatment. 

For Medicare Advantage Members

If you are a Medicare Advantage beneficiary, the easiest course of action is to call your plan’s doctor referral phone number, or visit their website and find a doctor who’s in your plan’s network. 

When Your Doctor Does Not Work With Medicare at All

Sometimes people really want to see a specific doctor, even though that doctor does not take Medicare assignments at all. These doctors are called “opt out” providers.

The good news is, if you’re receiving services that are covered under Original Medicare, you can still see that doctor and receive the benefit of Medicare coverage.

However, you may need to pay the cost of treatment up front, and then apply to Medicare to get reimbursed after receiving treatment.

See the section below, “How to Get Reimbursed By Medicare,” for more information on how to get reimbursed for money you paid in advance for Medicare-covered services.

Medicare Treatment and Outside Financing

Some people put smaller out-of-pocket costs on a credit card pending reimbursement. The advantage with this approach is there is an interest free grace period for new credit card charges.

If you need to pay the entire cost of treatment up front, however, that can be more difficult. The amount may beis usually bigger than most personal credit card limits.

However, many physicians’ offices work with outside consumer finance firms to allow patients to stretch out the payments and keep them affordable. This is also an option: you can finance the treatment, and then pay down the balance when you get your Medicare reimbursement. 

Negotiate a Discount

If you have to pay out of pocket for excess charges as a Medicare patient, you may be able to negotiate a discount with your provider. Most physicians will work with cash pay patients.

Visit an Urgent Care Clinic

Many Medicare patients will simply visit an urgent care clinic for many medical issues. Nearly all of them will take Medicare assignment, and it’s easy to get an appointment.

This course of action may be pricey compared to a doctors’ office visit in many cases. If you haven’t met your deductible, – or, for Medi-Share 65+ members, your $500 annual household portion, it may be more cost effective to schedule an office visit for routine care. 

How to Get Reimbursed By Medicare

To get reimbursed for Medicare-covered services you have paid for up front, fill out a Form CMS-1490S, or have your provider’s office complete it, with supporting documentation, including invoices and receipts for payment. Follow the instructions at the link provided. 

Search the Medicare Directory

You can find Medicare participating physicians near you by consulting the Medicare Physician’s Compare Directory. This is a complete list of all physicians, searchable by specialty and location. 

Once you find a candidate from the directory, call their office and ensure they are still taking new Medicare patients before showing up. This can save you a lot of time later.

Ask for a referral 

If your preferred doctor won’t take you as a Medicare patient, you can ask them for a referral to another doctor who will. 

Medicare Exclusions 

Some services are just not covered under Medicare at all. These include cosmetic surgery and alternative medicine, most dental care, eye exams, and long-term custodial care.

In cases like these you may still have some coverage under a workplace plan or a private insurance plan. For example, some Medicare Advantage plans provide limited coverage for hearing and vision. Or you can also purchase a separate dental insurance or visiondiscount plan.

You may need to find a participating provider.

If you are a veteran, you may also be eligible for some coverage under the Veterans Administration, depending on your status and if your medical condition has a service-related nexus.  

Conclusion

Dealing with a doctor who won’t bill Medicare or doesn’t accept Medicare can be challenging, but it doesn’t mean you’re out of options. 

By understanding the reasons behind non-acceptance or non-billing, exploring different options such as healthsharing, private insurance, and Medicare reimbursement, you can ensure you receive the care you need while maximizing your Medicare benefits. 

Here’s to your health and wealth,

Wiley P. Long, III
President – MediGap Advisors