DO ALL DOCTORS ACCEPT MEDICARE?

No, not all doctors in America accept Medicare.  There are a few that do not accept it, but the overwhelming majority of physicians and other Healthcare professionals do accept Medicare.

Did you know that there are over 1,000,018 Doctors in the USA? And, about 9.46 Doctors out of 10 accept Medicare Assignments. The largest group of Healthcare Professionals who do not accept Medicare are Psychologists, Pediatricians, and Psychiatrists.

According to the Kaiser Family Foundation, the states with the lowest percent of physicians accepting new Medicare patients include Utah and Oregon at 79%, then California, Nevada, Washington, Alaska, Maine, and Maryland at between 80% and 82%. Followed by Montana, New York, and Connecticut at between 83% and 84%. The data suggests that the percentage is lower in states that have a Medicare Birthday Rule in place.

If your doctor, hospital, clinic, specialist, or other healthcare provider accepts Medicare Parts A and B, they must accept any Medicare Supplement plan from any insurance company. That is because it is required by law. Doctors are not required to accept Medicare Advantage plans or Medicare Part C patients/members. The late nationwide estimates calculate that only 46% of the total number of Doctors in America accept any Medicare Advantage plans at all.  And, many of those only accept 1-4 plans.

Doctors do not like Medicare Advantage plans, and the percentage of Doctors prove this year after year.  Just over 20% of all Medicare Advantage (Medicare Part) plans have a physician/provider network that is made up of 70% or more of the available licensed doctors in their areas. 43% of Medicare Advantage plans have networks that include only 30% to 69%  of the total number of doctors who are licensed in the areas where the plans operate. And, a little more than one in three Medicare Advantage plans consist of networks that have under 30% of all available, licensed physicians in the areas where their plans are available.area physicians that accept Original Medicare. A full 35% of  Advantage plans have networks limited to less than 30% of doctors who accept Medicare in their area of coverage.

Doctors hate the pressure they receive from Medicare Advantage Plans to constantly lower their fees, and they also do not like telling Medicare Beneficiaries that they will need to get multiple referrals for a procedure that they believe is Medically Necessary.  They are frustrated with hearing about the complaints from Members.

Medicare enrollees 65 and older are the fastest-growing demographic in the U.S.
17% of the U.S. population was age 65 or older as of 2020, and that number is projected to grow north of 22% in 2039.

Just 3 years ago 5 million people who were at least 65 years of age were living below the Federal Poverty Level in the US. And, if that isn't startling enough, an additional 2.6 million people considered themselves to be nearly broke or almost poor. Combined that is almost the same number of people who live in the entire state of Maine! These are the demographics who are most likely to enroll in a Medicare Advantage plan because they cannot afford the premiums associated with a Medicare Supplement or Medigap plan.

In 1990, only about 3% of doctors opted out of Medicare, but recent reports indicate a decrease in that number. In 2020, approximately 1% of doctors chose to opt out. Factors such as hospitals acquiring medical practices and new doctors preferring to join medical groups (which involve them in Medicare) contribute to this trend.

Medicare-age patients are the largest and fastest-growing demographic of medical patients. In addition, Original Medicare and Medigap plans pay within days or weeks of receiving a bill. Months faster than the average turnaround of private health insurance or Advantage plans.

In all states except  Alaska, Colorado, and Wyoming, the percentage of physicians who have opted out of the Medicare program is less than 2% in each state.

So, do all doctors accept Medicare? No, but almost all.

According to the KFF, the independent source for health policy research, polling, and news, most non-pediatric office-based physicians accept new Medicare beneficiaries, as well as new private insurance patients.

Based on an analysis using data from the 2019 National Electronic Health Records  Survey (NEHRS), it was found that 89% of physicians accepted new patients who used Medicare in that year. Similarly, 91% of physicians accepted new patients with private insurance.

Among primary care doctors, the acceptance rates were slightly lower but still comparable,  with 83% accepting new patients with Medicare versus 86% accepting new patients with private insurance.

The analysis also revealed that the percentage of non-pediatric office-based physicians accepting new patients with Medicare remained consistent between 2011 (88%) and 2019.

If you need Medicaid services, however, you may have more trouble finding a  primary care doctor who accepts your insurance. Only 45% of primary care physicians accept new Medicaid patients according to KFF. Nearly one in every three Primary Care Physicians in the United States currently are not accepting "new" Medicaid Beneficiaries.

There are always discussions regarding the adequacy of Medicare payments for physicians and concerns about potential access issues if Medicare rates were implemented.

However, cash flow is key to a medical office's survival. Unlike other types of health insurance, Original Medicare pays within 2-weeks of receiving a bill. Most Medigap plans pay over 85% of claims within 48%. That creates a positive cash flow that is key to any medical office's sustainability.

Medical providers are not required to accept Medicare. The decision to accept or not accept Medicare is up to each individual doctor or healthcare provider.

We are often asked by clients what the best practices are to find physicians who 1) Accept Medicare and 2) Are currently accepting new patients.  So listed below are some of our top suggestions. 

To find a doctor who accepts Medicare, you can:

•  Here is the link to a free Physician Finder Search Tool on the Medicare Website: https://www.medicare.gov/care-compare/
•  If you have had any doctors in the past who you liked, the best course of action is to call their office and let them know you are either a current or former patient and you are about to enroll in Medicare and just ask them if their office accepts Medicare.
•  Talk to your primary care physician who might be able to recommend other doctors who accept Medicare patients.
•  Ask friends who may be on Medicare if they know whether or not their doctors are accepting new patients.
•  If you have a Medicare Advantage plan use the Provider tool on the insurance company's website. Remember though, less than half of the Doctors licensed in the United States accept Medicare Advantage, that number is around 45%. Once you find a doctor who says they are accepting new patients, call the doctor's office to verify that  A) The Doctor is still associated with your specific Medicare Advantage plan, and B) they are accepting new patients. 
•  Hopefully you worked with or are currently working with a licensed, independent Medicare Broker or Medicare Agent.  We encourage you to ask them for help with anything, whenever you need it, including assistance with finding doctors.  Brokers will always make time to talk and help you as much as they can.  

When a medical professional chooses to work with Medicare, they have two options for annual contracts: Participating Provider or Non-Participating Provider.

A  Participating Provider agrees to accept the Medicare-approved rate for services and bills Medicare directly, not the patient. This agreement is known as Medicare assignment. When a doctor accepts an assignment, they are referred to as being a "Participating Provider".

By law, doctors and physicians who accept Medicare Assignments are not permitted to charge anyone with Part B Excess Fees/Charges.

A big advantage for doctors who do accept Medicare's Assignments is the often overlooked fact that Medicare takes care of the entire Billing Process! For Doctors who do accept Medicare, the doctor only needs to submit a bill for  Medicare. Medicare then sends payment to the Doctor and they automatically send out a notice to the Medicare Beneficiary's Medicare Supplement /Medigap plan to pay their portion. Medicare electronically communicates with every Medicare Supplemental/Medigap Insurer and they provide them with all of the instructions they need to follow. Including,  who to pay, when to pay them, and who the payment is on behalf of. 

When a doctor intends to bill the patient more than the Medicare assignment rate, they can choose a contract as a Non-Participating Provider with  Medicare. Being a non-participating doctor in the Medicare program means they are not required to accept assignments and they are then authorized to charge Medicare Part B Excess Fees, if they decide to do so.  Many surveys suggest that less than 25% of Doctors actually charge the additional 15%. This, is obviously, not a good look and is one of those situations where nobody wins.

This is a less-than-ideal scenario for all the parties involved. So here is what Medicare has done to incentivize doctors to accept Medicare's Fee Schedule:

1. To begin with, Medicare will reimburse non-participating providers 5% less than they pay participating providers. Then, non-participating providers can only bill a maximum of 15% more than the Medicare reimbursement rate. In the end, the doctor will receive only 9.25% more compared to accepting a Medicare assignment.
2. A huge benefit to every Medicare Provider is the fact that Medicare handles and coordinates all of the billing for them.  This saves a Doctor's Office many hours a month and a significant amount of money every year.  In fact, this is one of he major "Benefits" of Accepting Medicare. 
3. If a Doctor determines that it is not in their best interest to "Accept Medicare" they become labeled as a Non-Participating Provider. The consequence of being a Non-Participating medical provider is that Medicare will not handle the billing process as a one-stop billing, although the doctor’s office will still be required to send a bill to Medicare, Medicare will not forward the bill to Medigap plans. Since the doctor lacks a contract with Medigap plans, they cannot bill them either. Instead, they usually require patients to pay for services upfront and then seek reimbursement directly from their supplement insurance company. This is the worst-case scenario for the Medicare Beneficiary because they typically will need to complete two separate CMS 1940s Forms, one for Medicare and one for the Medicare Supplement Carrier to be reimbursed.  Because of this, we strongly encourage each of our clients to ONLY see Doctors, Physicians, Clinics, and Hospitals that accept Medicare Assignments.
4. A physician's office must notify you ahead of time or display a conspicuous sign that alerts you to a potential excess charge. 

If a doctor accepts Original Medicare and Medicare assignment, they are required to accept any Medigap plan that you have, from ANY insurance company. Remember, they don’t bill the Medigap plan, Medicare does.

According to the Kaiser Family Foundation report, Medicare enrollees who do not have supplemental insurance face challenges in finding doctors who accept Medicare without a supplement. So it’s recommended that these patients consider investing in Medicare supplement insurance.

Not all doctors accept Medicare Advantage plans. Part C Advantage plans have networks of doctors and healthcare providers who have agreed to accept the plan’s terms and conditions. These networks vary between different Part C plans.

One of the major disadvantages of Medicare Part C is the fact that they have a lot of issues with their networks being small and therefore very limited in certain areas of the country. weakness of Advantage Plans is their limited network.

A little over one in every five Medicare Advantage Plans has a network that consists of 70% of doctors who accept Medicare in their area. 43% of Advantage plans have networks that include only 30% to 69% of area physicians that accept  Original Medicare. A full 35% of Advantage plans have networks limited to less than 30% of doctors who accept Medicare in their area of coverage. When you have a Medicare Advantage plan,  you need to review the plan’s provider directory or contact the plan directly to verify if your preferred doctors and healthcare providers are in-network. Seeing an in-network provider typically results in lower out-of-pocket costs and ensures that the services are covered by your  Advantage plan for a Medicare-approved amount.

In surveys conducted by the well-known Kaiser Family Foundation (KFF),  less than 50% of doctors who are contracted with Medicare, accept some  Advantage plans (aka Medicare Advantage). Even then, they may not accept your plan. The networks of doctors can vary depending on each Medicare plan and can change annually.

Medicare enrollees who do not have supplemental insurance face challenges in finding Doctors who accept Medicare without a supplement. So it’s recommended that these patients consider investing in Medicare supplement insurance.

Doctors do not normally accept all Advantage plans, nor are they required to do so. These Medicare plans have their own networks of doctors and healthcare providers who have agreed to accept the terms and conditions of specific plans. Provider network and health coverage can vary between different Advantage plans.

Unlike  Original Medicare, Part C medical providers enter into separate annual contracts with doctors and healthcare networks for medical services. And, in many cases, Doctors generally make less money from Medicare Advantage plans than they would from Original Medicare.  However, they usually reduce their Marketing and Advertising budgets, because of the amount of business they can potentially receive from MA plans.

Most established Doctors do not Accept Medicare Advantage plans. They do not want to rely on an Insurance company to dictate their terms and honestly, they are just not accepting of the constant low ball tactics that MA plans to place on them and they know all of the horror stories they hear directly from their patients.

I hope  you enjoyed this article and I hope you have a clear understanding about what it means for a doctor to "Accept" Medicare Assignment.  

If you have any questions about anything having to do with Medicare, please text, email or call us anytime it is convenient for you.