Family Care is a Non-Participating Provider with Medicare. What does that mean?

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

  • 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!

Family Care is In-Network with United Healthcare!

Family Care is in-network with United Healthcare!

As of February 10, 2016, Family Care is now considered an in-network provider with United Healthcare! For all United Healthcare patients at our office, this means…

  • Visits at our office will now be subject to your in-network benefits on your insurance plan. You will now have full access to the benefits on your plan for services at our office!
  • In-Network co-payments, co-insurances, and deductibles will apply to your visits. No more high out-of-network deductibles!
  • Annual preventive wellness exams (for non-grandfathered plans) are covered 100%! No more denials for preventive care services!

For an average patient that came in every three months as an out-of-network patient, this means out-of-pocket savings of anywhere from $150 (for high-deductible plans) to $400 (for regular co-payment plans)!

Why did we decide to re-join the UHC network? 

If you have recently signed up for health insurance on the individual marketplace, you may have noticed that there are far fewer options available to you than there have been in years past. For the 27713 zip code, and most of the surrounding zip codes, BCBS has limited their available products on the individual marketplace to their Blue Value and Blue Local plans only. Because the Value and Local plans are affiliated with the UNC and Duke healthcare systems (and our office is fully independent), many of our patients were left without an option that would be considered “in-network” at our office.

Now, after signing an in-network contract with UHC, patients who sign up for insurance on the individual marketplace have the option of selecting a United Healthcare plan to receive in-network insurance benefits for visits at our office. We hope this helps our patients save money and get the most out of their healthcare budget.

If you are a new patient to our office, Dr. Elaina Lee and Sarada Schossow, PA-C are currently accepting new United Healthcare patients.

Please contact our office to schedule an appointment today!