We need to go over a bit of history to understand that Medicare was created to help Senior Citizens 65 and older, younger disabled individuals, and those on Medicaid needing coverage. There is quite a bit of paperwork that the physicians and their staff need to fill out and comply with to get paid for services from the Medicare and Medicaid system.
There are many doctors and physician groups that are opting out of the Medicare system for a variety of reasons. First and foremost, Medicare limits the amount that a physician group can charge, this is called Allowable Charges. Over time this amount has become reduced and reduced and many physician groups have seen in their practices the greater chance of losing money.
Some groups of doctors will still accept Medicare patients, but they do this on an opt-in basis, this means that the patient would be responsible for the remaining bill or at a minimum 15% above the recommended services allowed by Medicare. These types of practices are known as opt-in or non-participating doctors.
Are Doctors Allowed to Refuse Patients?
In a nutshell, the answer is yes but there are some conditions that might need to be discussed. With all types of insurance, the practice is allowed not to accept Medicare Patients if this is the only payment that the patient has access to. Obviously, if it is an emergency, all Medicare Patients are guaranteed treatment but only on an emergency basis.
Many doctors are now refusing to accept many forms of payment from insurance companies due to the length of payment and reduction in acceptable amounts. Quite frankly, many doctors are tired of losing money while treating patients and have decided to opt-out of networks.
Do you have any rights if you are denied service?
One of the biggest issues for Seniors is having to change their physician due to network issues or the physician not willing to accept Medicare as an insurance plan. All is not lost; step number one is to contact the Medicare Advantage provider and ask for a copy of the physicians’ directory. In the past, we have found that a physician might not be listed in one location, yet upon further examination, they are listed at one of their other locations. This is because the Medical License number only allows one location to be listed. Recently, we discovered this loophole with a client who listed his primary care physician at one location, and the physician practiced at 7 locations. His license was parked at another location. The physician was in fact part of the network.
A less popular option is to pay cash for services. If the physician or physician’s group is not part of the network you can try and negotiate a lower cash rate with the physician. Obviously, the physician is not going to advertise this option but usually will work with you to figure out a reasonable solution for you the patient, and the physician.
Most physician and physician groups are aware if they opt out of a network, their current patients will be looking for another physician to work with. They are usually ready to recommend a colleague who they are familiar with and will accept Medicare Patients. Most receptionists or office managers are willing to assist in the process and do everything to help you with a change of doctors.