Communicating “Participating in Medicare” or “Not”

With increasing frequency, new-to-Medicare patients contact me with the question,  “My doctor says they don’t accept Medicare.  What does that mean?”

And each time I’m asked I think “Oh, if only I could answer with absolute certainty”.  The problem is, I’m not sure what message the doctor’s staff is hoping to convey.  Are they saying “No, we are not participating with Medicare, but we will file your claim for you and the Medicare reimbursement will go to you?” Or are they saying “Our doctor has opted out of Medicare and you will be responsible for the entire bill?” There is a big difference in these two explanations of “not accepting Medicare”.  And I have learned that,  in some cases, staff members use terms that are vague or somewhat confusing when explaining status on Medicare participation.   Let’s take a closer look at the 3 options.

Option 1.  Physician participates in Medicare.  This option is usually not a problem. It means that the physician accepts Medicare’s allowable as payment for services.  Medicare will pay 80% of the allowable, and the patient (or the Medicare supplemental insurance) is responsible for the remaining 20%.  For services “not allowed by Medicare”, the patient should have been presented an Advance Beneficiary Notice (see earlier post) to sign explaining the amount he could have been expected to pay.

Option 2. The physician is non-participating.  Here, the  physician elects to be a  non-participating physician.  In this case, the physician may directly bill the patient  the Medicare’s limiting charge which is 115% of the Medicare allowable. (The limiting charge is provided by the physician’s local carrier and is available on the website).  The physician submits the claim to Medicare, the reimbursement check goes to the patient and the patient is responsible for paying the physician.

For physicians to consider, if you choose to be a non-participating physician, you must still submit the claim to Medicare, but the reimbursement will go directly to the patient.  While you are allowed to collect 15% more for the service, you will be responsible for collecting the entire amount from the patient. The question that you must ask is “Can I be successful in collecting all money due me from the patient if the check goes to him?” 

Option 3.Opt out physician – In this scenario, the physician has advised Medicare that they choose to “opt-out” of Medicare for a 2 year period.   During that 2 year period, the physician is allowed to enter into private agreements with patients where they agree to pay him or her the set fee. There is no Medicare control over what that charge may be. Medicare will cover no services rendered by this physician, and the patient will be responsible for the entire bill.  The patient further agrees that no claim will be submitted to Medicare. 

The full regulations for Opting Out can be found at :

Option 4.  Not accepting new Medicare patients –  While the compliance piece of this option is questionable, there are those physicians who participate in Medicare or are non-participating in Medicare who are limiting the number of new Medicare patients they accept.  We mention this option here, only to cover all options. In this option, the physician is either a participating or non-participating physician with Medicare, but because of reimbursement or the follow up work involved with being a non-participating physician have limited the number of Medicare patients they accept into the practice. When a new Medicare patient calls for an appointment, the response may be that “We are not accepting new Medicare patients.”  This option has nothing to do with the first 3 options.

What does all this mean to a Medicare  patient?

Option 1 – Physician participates in Medicare:  In all likelihood, when a patient calls for an appointment and says they are “Medicare”, it will be business as usual. The appointment setter may ask for the insurance information, and the appointment is set.  The practice submits the claim, Medicare pays, the secondary insurance pays and the patient is only responsible for those charges he signed for on an Advance Beneficiary Notice.

Option 2 – Physician does not participate in Medicare:  When asked the question, “Does your doctor take Medicare?”  The answer should be, “Our physicians are not enrolled with Medicare as participating physicians. This is how it will work for you.  We will submit the claim for you and you will be responsible for paying us (at the time of service).  Our fees are 15% higher than the Medicare allowable, so you will be personally  responsible for that extra portion of the bill.”

Option 3 – Physician has opted out of Medicare:  When asked if your physician accepts Medicare, the answer would be “Our physicians are not enrolled in Medicare. We enter into private agreements with our patients where they agree to pay our fee and they also agree not to submit a claim to Medicare.” 

By clearly explaining your participating/non-participating/opting out of Medicare status,  you will have improved customer service, eliminated confusion at the time of the visit, and provided your patients with the information they need to make an informed decision.

This entry was posted in CMS and Compliance, Coding and Billing and tagged , , , , , . Bookmark the permalink.

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