What Should I Do If My Doctor Stops Accepting Medicare?

Why Are Some Doctors Opting Out Of Accepting Medicare? How Often Does This Happen?

Centers for Medicare and Medicaid Services estimates that in July 2024 (latest available data as of 12/26/24), 89.4% of people age 65 and over were enrolled in Medicare, and 50% of Medicare beneficiaries had Medicare Advantage. This is half of the senior population who rely on the coverage that Medicare Advantage provides and the ability to use their Medicare provider’s network without being exposed to additional out-of-pocket expenses. However, the relationship between many U.S. health systems and Medicare Advantage seemed to worsen over the past few years when many health systems chose to no longer participate in Medicare Advantage, with 32 of them dropping in 2024.

Amongst the most cited reasons for this decision are delays and denials in prior authorizations and payments from Medicare and low payments to the hospital systems that are not aligned with market rates. On a micro-level, many physician’s offices struggle with bureaucracy, which is a direct effect of the multitude of Medicare rules and regulations and the unwritten necessity of hiring a legal counsel to keep up with Medicare’s newest developments and requirements. The possibility of conflicts that the providers can run into with Medicare regulators (fear of the False Claims Act), along with small Medicare reimbursements that are not enough to keep their offices running, is an unfair battle where not only physicians but most of all Medicare beneficiaries are losing. 

Dealing with such a task alone is not easy. The expertise of a Board Certified Patient Advocate (BCPA) has successfully helped Medicare beneficiaries navigate the challenges of the healthcare system while offering a much needed peace of mind, especially when facing rare illnesses and invisible chronic conditions that require a specialized approach and long-term care.

What Should I Do If My Doctor Stop Accepting Medicare? Are There Ways To Negotiate With The Doctor, Or Should I Just Get A New One?

Once the doctor chooses to opt out of Medicare, Medicare won’t pay for any service provided by this physician, even though the service falls under the umbrella of Medicare-covered services. In this case, patients are required to pay the full amount at the time of service unless a separate arrangement is being made with a provider, such as a payment plan. Doctors who decide to opt-out can charge more than a Medicare-approved amount and are not obliged to comply with the 15% limiting charge rule that prohibits charging patients 15% over the Medicare-approved amount. 

Staying with the doctor who opted out of Medicare and choosing a private contract is the most expensive option, and Medicare beneficiaries are required to cover the out-of-pocket cost, which is often higher than the original Medicare-approved charge. Despite the higher cost, it may be a viable option in situations when a provider is one of the few specialists with expertise in a particular illness and when his or her treatment plan has already brought the desired results. In this case, negotiating with the doctor and asking for a discount when paid in full (or cash) or asking for an extended payment plan may be an option for some who can afford extra out-of-pocket charges or a temporary solution until finding a new provider. In this case, to avoid ambiguity and future surprises when it comes to unforeseen charges, Medicare beneficiaries should ask the provider for a private contract specifying services that are covered and fees associated with them.

To avoid unexpected bills and charges owed to a physician’s office, it is important to check periodically with the provider if he/she is still accepting Medicare. Providers can opt out of Medicare anytime throughout the year and not only before the next enrollment period. What’s even more troublesome for Medicare beneficiaries is the fact that the Medicare listings with participating providers are not being continuously updated on the Medicare website. Checking with the office prior to scheduling the next appointment may save a lot of time and money in this situation.

What Alternatives Do I Have If My Doctor Stops Taking Medicare?

Another more affordable option could be signing up with a concierge doctor who accepts reimbursements from Medicare but requires patients to pay a membership fee that has to be fully covered by Medicare beneficiaries. Concierge care may also offer some additional services and amenities (not originally covered by Medicare) that may come without extra charges. 

In terms of the concierge model, doctors who accept the assignment (Medicare’s approved amount) can’t charge patients extra for Medicare-covered services (or include these charges in the membership fee). On the other hand, providers who don’t accept the assignment can charge patients more than Medicare with a 15% limitation charge. 

Switching to a new provider may also be a viable option for some Medicare patients. In this case, they can use the Physician Compare Directory, which allows them to access and browse a national directory of providers accepting Medicare. To ensure coverage, it is important to confirm the provider’s Medicare status with his/her office prior to booking an appointment in order to avoid any unexpected out-of-pocket charges.  

For basic medical needs and routine appointments, Medicare beneficiaries can also consider using an urgent care facility or a walk-in clinic, as most of them accept Medicare. 

What Else Do You Want Readers To Know About Medicare And Finding A Good Doctor?

It never fails to ask for recommendations when choosing a new doctor. Checking with current physicians, family and friends, as well as neighbors is the easiest way to get more information about providers and things that are important for patients, such as bedside manner, length of practice, or expertise in a specific field. Another source of great referrals can come from a community, especially when it comes to dealing with a chronic illness that requires long-term care. Joining online support groups can provide both knowledge and resources when looking for a new physician. 

Another viable option is reaching out to a Board Certified Patient Advocate (BCPA) who can take on this task, do the research, and provide solid recommendations. BCPA can also speak with a prospective provider’s office beforehand on the patient’s behalf, confirm details such as coverage and availability, and connect with the office manager or provider on the details of care that are important to the patient. 

Hiring a patient advocate or healthcare navigator could be a great resource for patients who need a second opinion before surgery in NYC and who deal with chronic illness(es) or symptoms that go undiagnosed for years when getting specialized long-term care is essential. In many cases, working with a BCPA and switching to a new doctor may shed light and provide new insights into a patient’s long-lasting condition or symptoms, which can make a world of difference when it comes to treatment and management of chronic illness. 

At HealthCare Redefined, we simplify the process of finding the right Medicare options and connect you with trusted healthcare providers. Our services go far beyond advocating for women’s health and elder care advocacy in New Jersey/New York City. For more information, you can reach out to us, and our team of expert healthcare advisors will provide personalized assistance and guidance.