What happens if an aging parents needs or wants to go to a doctor that does not participate in Medicare? This situation has came up for us, and it may also be an issue for others.
While most Medicare health claims are submitted by a person’s doctor or health provider, navigating the Medicare highway can be a challenge because physicians and providers participate in Medicare in different ways. A patient or family needs to confirm whether or not a health provider participates in Medicare and to what degree. Some providers do not fully participate in Medicare and others do not participate at all. Here are the three ways the doctors do or do not participate.
- When a patient visits a participating physician, that doctor or provider agrees to accept the assigned fees (called assignment) from the Medicare program. Other than co-payments (and the annual deductible) a patient is not billed for any additional fees.
- If a physician is non-participating in the Medicare program, he or she may or may not accept assignment (the fee that Medicare assigns) so the fee may be higher. In this case the patient pays the provider, sends the claim to Medicare, and Medicare pays the patient the assignment amount. The physician can bill the patient 15% over the assignment.
- Some physicians do not enroll in Medicare. In this case the patient pays the full charge, but because the physician does not belong to Medicare (is not enrolled), the patient cannot submit a claim to Medicare. If a person has secondary insurance, the patient may be able to send the claim to that company.
Here are some links to reliable information.
- Money in the Middle blog. Laura, the blog’s author, provides basic, getting-started information on Medicare.
- Medicare News Blog features links to articles about current issues and news stories.
- Caregiving.org Medicare information and resources
- Medicare website section for Caregivers
- Questions about Medicare at Medicare.gov
