What happens when you visit a Non-Participating Provider with Medicare?
Family Care is a non-participating provider with Medicare, which basically means we do not accept assignment (ie. receive money) from any Medicare program. This is a brief summary of what that means from Medicare.gov:
You might have to pay the entire charge at the time of service. Your doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare-covered services they provide to you.
They can’t charge you for submitting a claim. If they do not submit the Medicare claim once you ask them to, call 1‑800‑MEDICARE.
They can charge you more than the Medicare-approved amount, but there is a limit called “the limiting charge “. The provider can only charge you up to 15% over the amount that non-participating providers are paid. Non-participating providers are paid 95% of the fee schedule amount.
While most non-participating providers will force you to leave the practice, we allow new Medicare patients to remain at our practice because we do not think insurance companies, even Medicare, should dictate who you are allowed to see as your primary care provider. Family Care will attempt to make the process simple, but there are some unavoidable downsides you should expect when considering remaining as patient and visit a non-participating Medicare provider:
- You will be required to pay up front for your visits. You pay us, we file your claim, Medicare pays you. These claims are included in your Quarterly Beneficiary Notice and any payments for approved services will be made directly to you, not to our office.
- You will need to wait 1-3 months for reimbursement. The full claims process usually takes 4-6 weeks, but Medicare should reimburse you ~70-90% of the amount you paid.
- If you pay us $100, we expect you to receive a ~$80 check from Medicare.
- Most services will cost ~10%-15% more than normal. An average Medicare visit costs $100, so you can expect to pay $7-$12 more per visit every time you have an appointment.
- If a service costs $100, you would probably only owe ~$10 at a participating provider, but you would end up owing ~$20 at Family Care.
We want what is best for our patients, even if that means helping them transition care to another primary care provider. We understand that this arrangement may not work for all patients and they might prefer a simpler process with an in-network / participating provider, instead. We are extremely grateful that many of our patients like our providers so much that they are willing to deal with these changes and remain patients at our practice. If you do wish to change providers, we can easily transfer your records to help make a smooth transition to a new provider.
To give you some positive news, here are a few reasons why you might want to stay as a patient, even though we do not accept your new Medicare insurance:
- We still file your claims with Medicare. You should not have to do any paperwork to submit your claims; you will only need to notify us in the event of a denial or non-payment so we can fix the issue.
- We will help you read your Beneficiary Notices. Every three months, Medicare will send you a summary of all charges incurred during the previous period. If you have any questions, Ryan would be glad to review the document with you to help you understand what happened.
- Our lab accepts Medicare. You will not have any additional costs or problems associated with a non-participating provider status for all lab samples and testing. These services would be processed as in-network with your Medicare plan and would be the same anywhere you go.
- Your Welcome to Medicare Exam is still covered. This initial screening within the first six months of your enrollment date has the same level of benefits for participating or non-participating providers.
- You can keep your provider. If you’ve been with us for a long time, we will be sad to see you leave!
We understand that learning the Medicare process can be like learning a new language. Their statements, forms, and processes are quite different than most commercial insurances, so there will be a learning process in the beginning regardless of where you go for care. You will experience many changes just because you are on Medicare, and then we add more exceptions to the rules because we are non-participating, so it can be a confusing process at first. If you remain as a patient, our hope is that we can make the process easy and clear. We will help guide you through the process so you are an expert on your Medicare coverage after you first couple of visits.
If you have any questions at any point during your transition, please ask Ryan!