Things are changing in healthcare–that’s not news. Secondary Insurance reimbursement for doctors who don’t take Medicare–is, to the best of my knowledge, up-to-date as of 12/1/20. Do check back frequently on this subject.

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

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

These doctors don’t “take” Medicare. They’ve chosen to be excluded from Medicare Program participation. Nevertheless, people with Medicare Part B  coverage can submit claims from these doctors to Medicare for reimbursement, IF they (the patients) have NOT signed a private  contract with a doctor who has opted out of Medicare participation.

In most cases, doctors opting out of Medicare will have you sign the private contract. All the opted-out doctors I’ve had experience with in NYC have patients sign the private contract.

Those who have Medicare Part B coverage (it’s an additional cost covering doctors’  bills but many have it)–and have secondary coverage through a private insurer can, however, bypass Medicare (which automatically sends to one’s secondary insurer) and submit the secondary insurer’s claim form directly  to the secondary insurer.

What’s Different?

You/your parents (not the doctor’s office) must do the paperwork and submit the following directly to Medicare if no private contract with the opted-out doctor has been signed.
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 and bypass Medicare

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 were reimbursed.

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, but NOT if you’ve signed the private contract with a non-Medicare-participating doctor. Send claim directly to your secondary insurer.

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

Next post: Filling out and filing the form: 1490S. As they say, “The Devil is in the Details.”

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