Fair Square Medicare Wordmark

What to Do When Your Doctor Doesn't Take Medicare

a doctor tells her patient she doesn't accept medicare. the patient wonders what to do stock image
By Daniel Petkevich
Feb 24, 2023

Simple Strategies to Manage Your Out-of-Pocket Costs

Navigating your medical expenses can be overwhelming, and it becomes even more challenging if your doctor doesn't accept Medicare.

Stay Up to Date on Medicare!

Join the Fair Square Medicare Newsletter to stay informed on cost savings, changes to Medicare, and other valuable healthcare information.
Let's look at how healthcare providers approach Medicare beneficiaries and what you can do when your doctor doesn't take Medicare.

Do All Doctors Accept Medicare?

No. Not all doctors accept

Medicare.

While some physicians may choose not to participate in the Medicare program, others may limit the number of Medicare patients they are willing to accept.
Some physicians may deny Medicare due to the following reasons:
  • Tedious paperwork — Tasks like paperwork, compliance checks and claims filing may burden smaller medical practices, leaving less time for patient care
  • Low reimbursement — For some physicians, the actual cost of the care provided is much higher than the reimbursed rate. In addition, the

    2023 Physician Fee Schedule (PFS)

    brings a potential reduction in Medicare fees for physicians ranging from 4.5% to 8.5%.
  • Stringent rules — Some doctors may not be able to comply with Medicare's strict rules
Before receiving medical care, it's essential to confirm that your healthcare provider accepts Medicare to avoid unnecessary out-of-pocket expenses.

How Doctors Approach Medicare Patients

If you're enrolled in Original Medicare, a significant factor that determines your Part B cost (after you've paid the deductible) is the type of provider you choose. Medicare classifies providers into three types.
Physicians or healthcare providers can register with Medicare as a:

1. Participating Provider

These providers accept "assignment" on all Medicare claims for their Medicare patients, which means they agree to accept Medicare’s approved amount as full payment for all covered services. Almost

98%

of doctors that bill Medicare are participating providers. 
When you receive care from a participating Medicare provider, you're only responsible for the cost-sharing amount required by Medicare. This means if you're on Original Medicare, you'll have to pay:
  • The Part B deductible, and
  • 20% of the Medicare-approved amount (coinsurance)

2. Non-Participating Provider

These providers accept Medicare patients but can choose to accept Medicare assignments on a claim-by-claim basis. Unlike participating providers, they're limited to only 95% of the Medicare-approved amount if they accept a Medicare assignment. 
In contrast to participating providers, non-participating providers can charge beneficiaries more than the Medicare-approved amount (not exceeding 15% of the fee-schedule allowed amount) — also known as the limiting charge. 
If you're seeing a non-participating provider, you'll have to pay for the following:
  • The

    excess charges

    — the amount above the Medicare-approved amount for a service
  • 20% of the Medicare-approved amount (coinsurance)

3. Opt-Out Provider 

These providers don't accept Medicare at all. They have private contracts with their Medicare patients, which allow them to set their prices for services without limitation. Fortunately, only a small number of doctors have chosen to opt out of Medicare
If you're seeing a provider who opted out of Medicare, you’ll be responsible for 100% of the cost of the service. You may also need to sign an agreement to be accountable for the total cost of your care, and neither you nor your provider can send a bill to Medicare for payment.

What to Do When Your Doctor Doesn't Accept Medicare

While healthcare providers across the country widely accept Medicare, your doctor might not, which may limit your access to the medical care you need.
Here are a few steps you can take if your physician doesn't accept Medicare.

1. Remain with Your Current Provider and Pay the Difference

If your doctor is a non-participating provider who chooses not to accept Medicare assignments, they may charge you more than the Medicare-approved amount for their services.
If you want to continue seeing your current doctor, you'll likely have to pay the difference between the fee charged and the Medicare-approved amount.
Note: You may even have to pay the entire bill during your doctor's visit and submit a claim to Medicare. To request reimbursement for the portion of the bill approved by Medicare, you or your doctor can submit

Form CMS-1490S

.
For example, suppose your non-participating doctor charges $200 for a specific service, but the amount approved by Medicare for that service is only $150. If your doctor agrees to accept the Medicare assignment, you'll pay the difference of $50 — in addition to the 20% coinsurance for the service, which amounts to $30.
Here's the math:
$50+ 20% ($150) = $50 + $30 = $80

2. Ask for a Referral

If continuing to see your non-participating doctor is not feasible due to financial constraints, it's worth asking your doctor to recommend another physician in your area who accepts Medicare.
Chances are your current doctor has encountered this situation before and may have already made arrangements to transfer Medicare patients to another doctor.
By asking for a referral, you may be able to maintain continuity of care and avoid the potential difficulties of finding a new physician on your own.

3. Ask for a Discount

If your doctor is a non-participating provider or has opted out of Medicare, and the cost of the medical service is not within your financial means, you can ask for a discount.
Some physicians may be willing to lower their rates for established patients. They may offer extended payment plans for patients needing expensive treatments or procedures.

4. Visit an Urgent Care Center or Walk-In Clinic

Urgent care centers are medical facilities that provide walk-in medical care for people who need to see a healthcare provider but can't get an appointment with their

primary care physician

. These centers offer various medical services, including treatment for non-life-threatening illnesses and injuries, lab services, X-rays, and other diagnostic tests.
Many urgent care centers and walk-in clinics accept Medicare and even serve as primary care practices for some patients.
If you're experiencing a minor illness, require a flu shot, or need a diagnostic test, visiting one of these clinics may be more cost-effective than scheduling a traditional doctor's appointment. You can save your doctor visits for more serious medical conditions.

5. Refer to the Physician Compare Directory

The

Physician Compare Directory

, an online resource provided by the Centers for Medicare and Medicaid Services (CMS) in the United States, allows you to search for physicians and other healthcare providers who accept Medicare.
Once you’ve selected a physician, we recommend you confirm with the provider's office to ensure they're still taking new Medicare patients, as this can change anytime.
You can also ask nearby hospitals whether they have doctors who accept Medicare.

6. Concierge Care

Concierge medicine is a healthcare model in which patients pay an annual (around $1,500) or monthly fee to a primary care physician or healthcare practice in exchange for personalized medical care and services. It includes several benefits like same-day or next-day appointments, 24/7 access to their doctor, personalized health and wellness plans, and coordination of specialist care.
Concierge Doctors may accept Medicare assignments, but you'll have to pay for the annual membership, as Medicare doesn't cover this cost. If you can afford it and anticipate regular doctor visits, concierge medicine is worth considering.
Here are some key points to think about when signing up for concierge care:
  • If your doctor accepts Medicare assignments, they cannot charge you extra for Medicare-covered services. This means your membership fee can’t include additional charges for items or services that Medicare usually covers unless Medicare won’t pay for that item or service.
  • If your doctor doesn't accept Medicare assignments, they may charge you more than the Medicare-approved amount for their services. But this amount should not exceed 15% of the Medicare-approved amount.
  • All Medicare doctors (whether or not they accept assignments) can charge you for services that Medicare doesn't cover. Review your specific plan's coverage for any additional fees associated with concierge care.

What's The CARES Act of 2020?

The Coronavirus Aid, Relief, and Economic Security (

CARES

) Act is a law the United States Congress enacted in response to the COVID-19 pandemic. The CARES Act was designed to provide financial assistance to individuals, businesses, and healthcare providers affected by the pandemic.
A few changes brought about by The CARES Act:
  • Improved Medicare coverage to incorporate

    COVID-19 testing

    , treatment, and services for beneficiaries. Medicare covers 100% of the COVID-test costs, including COVID-19 antibody (or “serology”) tests.
  • Telehealth services under Medicare are now more flexible, which enables individuals to obtain medical care while adhering to social distancing guidelines.
  • Medicare now certifies physician assistants, nurse practitioners, and certified nurse specialists to provide home health services to Medicare beneficiaries.
  • Medicare has increased payments for COVID-19 hospitalizations and medical equipment to help healthcare providers cover the costs of caring for COVID-19 patients.
Under the CARES Act, states that have not expanded Medicaid can still use the program to provide COVID-19-related services for uninsured adults who would've been eligible for Medicaid if their state had chosen to expand its coverage.
Other people with limited Medicaid coverage may also qualify for coverage under this option.

Stay Informed to Overcome Healthcare Challenges

It can be challenging to navigate your medical expenses, especially if your doctor doesn't accept Medicare.
Despite Medicare's widespread acceptance among healthcare providers, some doctors still choose not to participate.
You can explore several practical solutions to get the care you need.
Whether it's finding alternative providers, negotiating rates, or asking for a referral, options are available.
At

Fair Square

Medicare

, we empower you with the knowledge and resources you need to make informed decisions about your health care. If you have any questions or concerns about Medicare, call us at 1-888-376-2028. Our team of expert advisors can provide personalized assistance and guidance.

Stay Up to Date on Medicare!

Join the Fair Square Medicare Newsletter to stay informed on cost savings, changes to Medicare, and other valuable healthcare information.

Recommended Articles

Cover image
2024 Cost of Living Adjustment
Nov 13, 2023
Cover image
Does Medicare Cover Cold Laser Therapy (CLT)?
Jun 14, 2023
Cover image
Is Fair Square Medicare Legitimate?
Jul 27, 2023
A women's restroom sign that has been modified to show the stick figure woman needing to use the toilet
Does Medicare Cover Bladder Sling Surgery?
Jan 11, 2023
elderly woman with glasses having difficulty reading her phone stock image
Is Vitrectomy Surgery Covered by Medicare?
Dec 2, 2022
The feet of a person suffering from foot pain stock photo
Does Medicare Cover Cartiva Implants?
Nov 29, 2022
Cover image
Seeing the Value in Fair Square
May 15, 2023
Senior woman fretting in front of her laptop stock photo
How Medicare Costs Can Pile Up
Oct 11, 2022
Cover image
2024 Medicare Price Changes
Oct 30, 2023
Female physiotherapist helping elderly man in wheelchair do exercises with dumbbells at health center stock photo
What Does Medicare Cover for Stroke Patients?
Jan 20, 2023
doctor examining a patient's varicose veins stock photo
Does Medicare Pay for Varicose Vein Treatment?
Nov 18, 2022
Cover image
The Fair Square Bulletin: The End of the COVID Emergency Declaration
May 30, 2023
Doctor physician consulting with male patients in hospital exam room stock photo
Is PAE Covered by Medicare?
Nov 23, 2022
Cover image
2023 Medicare Annual Election Period (AEP)
Sep 21, 2023
Cover image
When to Choose Medicare Advantage over Medicare Supplement
Jun 7, 2023
Hands of doctor or nurse in medical gloves injecting a shot to a man patient stock photo
Does Medicare Pay for Allergy Shots?
Nov 29, 2022
Medigap on a post-it note surrounded by a stethoscope stock image
Do Medicare Supplement Plans Cover Dental and Vision?
Dec 8, 2022
Senior woman smiling after vaccination stock photo
Does Medicare Cover Flu Shots?
Dec 9, 2022

More of our articles

Building the Future of Senior Healthcare

Can Doctors Choose Not to Accept Medicare?

Can I Choose Marketplace Coverage Instead of Medicare?

Can I Laminate My Medicare Card?

Can Medicare Advantage Plans Deny Coverage for Pre-Existing Conditions?

Comparing All Medigap Plans | Chart Updated for 2023

Do I Need to Renew My Medicare?

Do You Need Medigap if You're Eligible for Both Medicare and Medicaid?

Does Medicare Cover a Spinal Cord Stimulator?

Does Medicare Cover Abortion Services?

Does Medicare Cover Air Purifiers?

Does Medicare Cover Bariatric Surgery?

Does Medicare Cover Boniva?

Does Medicare Cover Breast Implant Removal?

Does Medicare Cover Cataract Surgery?

Does Medicare Cover Cervical Disc Replacement?

Does Medicare Cover COVID Tests?

Does Medicare Cover Diabetic Eye Exams?

Does Medicare Cover Home Heart Monitors?

Does Medicare cover Hyoscyamine?

Does Medicare Cover Hypnotherapy?

Does Medicare Cover Iovera Treatment?

Does Medicare Cover Jakafi?

Does Medicare Cover Krystexxa?

Does Medicare Cover Kyphoplasty?

Does Medicare Cover Linx Surgery?

Does Medicare Cover Medical Marijuana?

Does Medicare Cover Mental Health?

Does Medicare Cover Mouth Guards for Sleep Apnea?

Does Medicare Cover Nexavar?

Does Medicare Cover Nuedexta?

Does Medicare Cover Ofev?

Does Medicare Cover Ozempic?

Does Medicare Cover Penile Implant Surgery?

Does Medicare Cover PTNS?

Does Medicare Cover Service Animals?

Does Medicare Cover SI Joint Fusion?

Does Medicare Cover the WATCHMAN Procedure?

Does Medicare Cover Tymlos?

Does Medicare Cover Urodynamic Testing?

Does Medicare Cover Xiafaxan?

Does Medicare Cover Zilretta?

Does Medicare Have Limitations on Hospital Stays?

Does Medicare Pay for Funeral Expenses?

Does Medicare Require a Referral for Audiology Exams?

Explaining IRMAA on Medicare

Explaining the Different Enrollment Periods for Medicare

Health Savings Accounts (HSAs) and Medicare

How Does Medicare Pay for Emergency Room Visits?

How Does the End of the COVID-19 Public Health Emergency Affect Your Medicare?

How Much Does Open Heart Surgery Cost with Medicare?

How Much Does Trelegy Cost with Medicare?

How Much Does Xeljanz Cost with Medicare?

Is Displacement Affecting Your Medicare Coverage?

Is HIFU Covered by Medicare?

Medicare & Ozempic

Medicare 101

Medicare Consulting Services

Medicare Explained

Medicare Supplement Plans for Low-Income Seniors

Plan G vs. Plan N

Should You Work With A Remote Medicare Agent?

The Fair Square Bulletin: October 2023

Welcome to Fair Square's First Newsletter

What Happens to Unused Medicare Set-Aside Funds?

What Is a Medicare Supplement SELECT Plan?

What To Do If Your Medicare Advantage Plan Is Discontinued

What You Need to Know About Creditable Coverage

What's the Deal with Flex Cards?

When Can You Change Medicare Supplement Plans?

Which Medigap Policies Provide Coverage for Long-Term Care?

Why You Should Keep Your Medigap Plan

Your Medicare One-Stop-Shop

Your guide to Medicare Parts A & B, Medicare Advantage, and Medigap. 100% free.
Get the Fair Square Bulletin

Medicare savings tips, helpful guides, and more.

About

Medicare 101

Current Clients

Medicare Supplement Plans

Medicare Advantage Plans

Fair Square 2024

Terms of Use
Notice of Privacy Practices

Virgil Insurance Agency, LLC (DBA Fair Square Medicare) and www.fairsquaremedicare.com are privately owned and operated by Help Button Inc. Medicare supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. This is a solicitation of insurance. A licensed agent/producer may contact you. Medicare Supplement insurance is available to those age 65 and older enrolled in Medicare Parts A and B and, in some states, to those under age 65 eligible for Medicare due to disability or End-Stage Renal disease. Virgil Insurance Agency is a licensed and certified representative of Medicare Advantage HMO, HMO SNP, PPO, PPO SNP and PFFS organizations and stand-alone PDP prescription drug plans. Each of the organizations we represent has a Medicare contract. Enrollment in any plan depends on contract renewal. The plans we represent do not discriminate on the basis of race, color, national origin, age, disability, or sex. Plan availability varies by region and state. For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov. © 2024 Help Button Inc

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

MULTIPLAN_FairSquareMedicare_01062022_M