Medicare Providers: Accept Medicare Assignment vs. Accept Medicare Patients

Now that you are enrolled in Medicare, you need to know which doctors allow you to utilize your benefits to the fullest. In order to maximize your benefits, you need to receive care from doctors who accept Medicare assignment.

Many people don’t realize that there are big differences between providers who accept Medicare assignment and providers who accept Medicare patients. In this article, we will discuss the differences and how they apply to your Medicare coverage.

An Example

You did your homework. You called your doctor’s office and asked if they took Medicare. The receptionist confirmed that yes, the office accepts Medicare patients. 

You think, “Great!” and schedule an appointment.

You go to your appointment that you think is mostly covered by Original Medicare. You plan to pay your copay, but nothing more.

And then a bill arrives in the mail. The amount due is more than your copay is supposed to be. You call the office, thinking there must have been a mistake.

The receptionist tells you that it is not a mistake. Their office accepts Medicare patients and files the claim on the individual’s behalf, but they do not accept Medicare assignment. You’re stuck paying a bill you weren’t expecting.

What went wrong? Did the office lie to you?

Not quite, although it would have been much more helpful if the receptionist had explained the differences between “accepting Medicare patients” and “accepting Medicare assignment.”

Providers Accepting Medicare Assignment vs. Providers Accepting Medicare Patients

Here’s the difference.

Accepting Medicare assignment means the provider will accept Medicare’s payment – negotiated fee considered fair by both parties. That means you won’t be paying more than what your Medicare plan has decided is necessary to provide coverage for medical services and supplies. This applies to procedures covered under Medicare Part B.

The catch is, even a doctor who does not accept Medicare assignment can provide services for a Medicare beneficiary. Many will also file the claim for their patient. However, if they do not accept Medicare assignment, they are allowed to charge up to 15% more than Medicare’s allowed fee. These are called Medicare overcharges or “Part B excess charges.” Excess charges occur when providers bill their patients for more than what Medicare has agreed to pay the provider.

For example, let’s say you go to the doctor and have a Medicare-approved procedure that costs $100 (according to Medicare.)

If that doctor does not accept Medicare assignment, they can decide that $100 is not sufficient reimbursement for that test. The doctor can choose to charge 15% more, which would amount to $15 ($115 total) for the test. This $15 is considered the Part B excess charge.

Which Doctors Accept Medicare?

The only way to prevent excess charges is to ask your doctor if they accept Medicare assignment. Make sure you use that term specifically and do not just ask, “Do you take Medicare?”

If you are scheduling a bigger procedure like a surgery, there is likely more than one doctor involved – like an anesthesiologist. Be sure to ask if all the providers on your care team accept Medicare assignment. It’s often the specialists that members forget to ask about.

The good news is, 95% of the doctors across the United States accept Medicare assignment. For that reason, excess charges are rare in most parts of the country.

Other Options to Prevent Excess Charges

Another option to ensure you do not pay Part B excess charges is to enroll in a Medicare Supplement (Medigap plan) or Medicare Advantage (Part C) plan that covers those extra charges for you.

Providers Who Opt-Out of Medicare

There are providers who have completely opted out of the Medicare system. If you see a doctor who has done this, neither the provider nor you will send a claim to Medicare as there will be absolutely no coverage for services rendered. You will pay the provider the full fee for their services. (Which can far exceed the extra 15%.)

Any easy way to find out if your provider has opted out of Medicare is to search the national database on Medicare.gov.

One Last Consideration

If you decide to enroll in a Part C plan, you will need to find out if you must receive care from an in-network provider. This is a separate qualification than accepting Medicare assignment.

Some plans only allow you to see in-network providers, otherwise, you may have no coverage if you go outside of your network. Others offer partial coverage for out-of-network services.

Again, be specific when you’re asking your provider this question. Don’t ask, “Do you take Company X patients?” Instead ask, “Are you in-network with Company X?” This will ensure you get the answer you are looking for and don’t end up with surprises later.

Medigap plans allow you to see any provider, as long as they accept Medicare assignment.

Fortunately, doctors who do not accept Medicare assignment are rare. However, medical bills can quickly pile up, so doing your homework in regards to your healthcare team is an important component to controlling the cost of your healthcare.