Your Doctor May Accept Medicare but Does He Accept Assignment?

The Medicare-Doctor Relationship

Doctor Nurses
Find out where your doctor stands with Medicare. Kristian Sekulic/Vetta/Getty Images

No one wants to pay more than they have to. That is exactly what you could do if you receive care from a doctor that does not accept your insurance. It gets even trickier with Medicare. Even if your doctor accepts Medicare for payment, he may not bill you the way you expect.

Doctors Who Do Not Accept Medicare

If you rely on Medicare as your only source of health insurance, you are out of luck when your doctor does not accept Medicare for payment.

Even if certain services would otherwise be covered by Medicare, the government has not established a contractual relationship with this provider. You will be billed by the doctor and expected to pay for all costs out of pocket.

If you have a supplemental Medicare insurance plan, you may be in a better position to save. It is not a guarantee that all costs unpaid by Medicare will be covered by your supplement. It will depend on the specific plan you have chosen.

Sometimes your hands are tied and you need to receive care from a doctor who does not accept Medicare. You may live an area where there are limited resources or few specialists available to diagnose and treat certain problems. If you find yourself in this situation, be sure to take the time to talk with your doctor’s office. They may be willing to set up payment plans to help you with your bills.

Doctors Who Accept Medicare

Whenever possible, you want to ask if your doctor accepts Medicare for payment.

This means that your physician is board-certified in their field, whether that is in primary care or a specialty. He has also signed a contract with Medicare and the government agrees to reimburse him for services he provides. The end result is less out of pocket costs for you.

While that sounds clear cut, there is more to the scenario.

Your doctor may accept Medicare for payment but not agree to all of Medicare’s conditions. This leads to the issue of participation.

Doctors Who Accept Medicare and Accept Assignment

Every year Medicare establishes a physician fee schedule. This fee schedule dictates how much a provider can charge you for a given service. Once a doctor accepts Medicare for payment, he then has a choice whether or not to participate in the fee schedule. This is called "accepting assignment".

If a doctor accepts assignment, he agrees to the rates set by the fee schedule. Under no circumstances can he charge you more for any service listed on the fee schedule. This protects you from regional cost fluctuations or needing to shop around for cheaper rates.

There are other benefits to choosing a participating Medicare provider. Certain preventive screening services offered by a participating provider are 100% free to you. You will pay a coinsurance for those same services, as much as 20% of costs, if you choose a non-participating provider.

Doctors Who Accept Medicare but Do Not Accept Assignment

Some doctors agree to accept Medicare for payment but disagree on the value of certain, or even all, services. In these cases, they may want to charge you more than what Medicare recommends on the fee schedule. These doctors choose not to participate.

Medicare will pay their usual amount for covered services but you may be billed an additional amount by the doctor. To keep costs from getting out of control, Medicare limits how much a doctor can charge you above the recommended fee schedule amount. This is set at a 15% limiting charge. For example, if the fee schedule lists a service for $100, the doctor could bill you an extra $15 but no more. You are liable to pay this extra amount out of pocket.

Take Home Lesson

You will save more money if you choose a participating provider.

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