*Note–November 2015–Awaiting Update that may negate the Part B Medicare coverage for some–although information about secondary insurance remains valid, I believe.

Some doctors don’t “take” Medicare.
They’ve chosen to be excluded from Medicare Program participation.

Nevertheless, people with Part B Medicare coverage are entitled to submit claims from individual doctors to Medicare unless they signed a form in the doctor’s office stating they would not file for Medicare benefits. Otherwise  regardless of a doctor’s Medicare affiliation, it entails a bit more work from you/your parents if you’re submitting 

Helping parents age well clearly includes their healthcare. And no doubt many parents have Medicare coverage, using doctors who “take” Medicare and do the paperwork so Medicare can reimburse. And this works pretty well.

But what happens when a parent with Medicare coverage uses a doctor who has chosen to be excluded from Medicare Program participation and thus, doesn’t “take” Medicare? More and more doctors in NY and probably other large cities have decided to be excluded from Medicare participation.

That said, it’s important to know and remember: People insured by Medicare, are covered by Medicare.  Assuming they did not decline Part B coverage (it’s an additional cost but many have it) and signed no waiver in the doctor’s office, they are entitled to Medicare reimbursement for individual doctor’s bills whether the doctor participates in Medicare–or not.

What’s Different?

You/your parents (not the doctor’s office) must do the paperwork and submit the following directly to Medicare:
1.  Medicare form called “Patient’s Request for Medical Payment” (*See below)
2.  doctor’s letter verifying his/her exclusion from Medicare
3.  the doctor’s bill

I recently attended a retirees’ program about health insurance. There were questions about doctors who don’t accept Medicare. Many in the audience were clueless.

Why Use a Doctor Who Doesn’t Participate?

You may require a specialist, and that particular specialist has opted out of Medicare participation.

One retiree in the audience, who had paid in full without any reimbursement, had been given the name of 2 specialists for a necessary delicate procedure. The doctor who accepted Medicare was on maternity leave. The patient couldn’t wait, thus needed to use the doctor who didn’t accept Medicare. Since she was unaware she could file her claim directly to Medicare, she “lost” that money. (Reimbursement is based on Medicare’s fee for service, no doubt less than non-Medicare-participating doctors’ fees.)

If You Have A Secondary Insurer

Some in the audience assumed Medicare wouldn’t pay, but had secondary coverage from another insurer. They submitted bills from the non-Medicare-participating doctors directly to their secondary health insurer and received some monies back.

In one case the secondary insurer had reduced her reimbursement by the amount it determined Medicare would have reimbursed her for the procedure, then subtracted their deductible, co-pay or whatever. Whether or not the “amount determined” was the amount Medicare would have paid is unknown. What is known is that her reimbursement was a very small amount of the original bill. Another retiree had a similar experience with his secondary insurer.

Medicare Will Send Information on to Your Secondary Insurer Afterward.

A non-participating Medicare doctor’s bill, exclusion letter, and Medicare form should first be sent to Medicare for reimbursement, which then sends everything on to the secondary insurer. There’s a place on the form (1490S) for the name and address of “Coverage Other Than Medicare.” There’s also a box to X, “If you DO NOT want payment information on this claim released.”  In any event, if you have Medicare Part B coverage, don’t bypass Medicare at the beginning.

While many have coverage under networks of doctors and the preceding information may seem unnecessary, emergency-type cases and in places where doctors have excluded themselves from Medicare, this knowledge will come in handy. (A retiree under 65 in the audience said she was heartened to have this information in advance.)

Note: Non-participating doctors’ office personnel are evidently not allowed to give advice about Medicare.
*          *         *

Medicare participants should have received Medicare & You 2015 in the mail late last fall. If questions are not answered in that booklet, contact Medicare directly (1-800-633-4227) For hard copy of booklet click: http://www.medicare.gov/Publications/Search/Results.asp?PubID=10050&Type=PubID –or download from: https://www.medicare.gov/gopaperless/home.aspx (If you download, I believe future publications will be emailed–double-check this.)

*For Medicare forms and instructions in English:  http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1490S-ENGLISH.pdf  Forms are also available in Spanish.

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