- 287
What's the difference between providers that have formally opted out of Medicare and Non-Participating providers in Medicare?
Docs Non-Participating Medicare & Opt Out of Medicare?
- Thread starter saintstigers
- Start date
-
- Tags
- medicare
- Thread starter
- #3
- 287
Why wouldn't a non-participating doc just go all the way and opt-out? What are the reasons a doc would want to stay non-participating?
- 1,735
If the doctor is opting out, Medicare won't reimburse the doc or the patient for treatment they receive by the opted out doc.
That is different from non-participating docs being eligible to bill patients at a slightly higher rate than participating docs. Net upcharge to rates is about 9.5%(might be 9.25, I don't recall just now), after the reduction Medicare takes off base rate before the doc can upcharge by 15%.
Some concierge doctor practices are splitting the difference, rather than opting out, by being participating physicians in Medicare for Medicare billable charges. They have wrap around non-Medicare services to the patient, such as more office time/consulting, and more you can read if you look up the website of a concierge practice. People I know who go to these docs are paying usually about $100/month for the concierge limited # of patients in the practice format, extra time, quick appointments, etc.
One of my recent T65's has a concierge doc he would have used anyway. Client was thrilled to know that some of his doc's costs would be covered well on his Plan G.
That is different from non-participating docs being eligible to bill patients at a slightly higher rate than participating docs. Net upcharge to rates is about 9.5%(might be 9.25, I don't recall just now), after the reduction Medicare takes off base rate before the doc can upcharge by 15%.
Some concierge doctor practices are splitting the difference, rather than opting out, by being participating physicians in Medicare for Medicare billable charges. They have wrap around non-Medicare services to the patient, such as more office time/consulting, and more you can read if you look up the website of a concierge practice. People I know who go to these docs are paying usually about $100/month for the concierge limited # of patients in the practice format, extra time, quick appointments, etc.
One of my recent T65's has a concierge doc he would have used anyway. Client was thrilled to know that some of his doc's costs would be covered well on his Plan G.
Last edited:
AllyriaRedbird
Expert
- 71
This is the wave of the future of doc's billing. In my home state, NM, the Office of the Superintendent of Insurance is considering a change to Med Adv Plans that would allow non-participating docs to pass the excess charges (by law up to 15%) onto seniors.
Complaints were made with the OSI regarding the fact that some Med Adv clients were billed for excess charges-even though they were in the right hospital with the right permission(s)-even though their Adv Plan doesn't allow it for services by a non-participating provider.
http://www.osi.state.nm.us/MiscPages/docs/newsroom/Surprise Medical Bills.pdf
As more and more docs take the option to make more money, more seniors will be blindsided by these unexpected bills for the "limiting charge/balanced billing/excess charges."
I heard of one senior who shook hands with a doc after he applied a band aid and received a bill for $1000.00.
- 2,370
If I remember right, roughly 4% of providers are non-participating.
The Mayo clinics are non-participating. This overview can help with how billing works when going to a non-participating provider:
http://www.mayoclinic.org/documents/mayo-clinic-medicare-and-you/doc-20078770
The Mayo clinics are non-participating. This overview can help with how billing works when going to a non-participating provider:
http://www.mayoclinic.org/documents/mayo-clinic-medicare-and-you/doc-20078770
- 2,370
Correct. Plans F and G will cover the excess charges. All other supplement plans the client will be responsible for the charge.
- 1,735
Do excess charges someone would pay on High Deductible F before meeting the max. out of pocket, (more accurate than deductible) go to the "deductible". I probably answered my question, since F covers excess charges. Just to confirm.
What's the deal with Mayo? Does everyone go there? Some people toss that around like going to Mayo is as common as going to McDonalds for a cheeseburger.
As I recall the non-participating deal started with Mayo in AZ (or maybe NM) and apparently has spread to other clinics. Looks like the MN clinic still accepts assignment.
Can't tell from the above if ALL Mayo's are required to accept assignment for the listed items or if that only applies to MN.
As I recall the non-participating deal started with Mayo in AZ (or maybe NM) and apparently has spread to other clinics. Looks like the MN clinic still accepts assignment.
More about Medicare - Billing and Insurance at Mayo Clinic - Billing
Can't tell from the above if ALL Mayo's are required to accept assignment for the listed items or if that only applies to MN.
Similar threads
