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BY IRENE C. CARD and BETSY CHANDLER
NEWJERSEYNEWSROOM.COM
YOUR HEALTH INSURANCE
A Medicare provider is a doctor who has been approved by Medicare to submit charges for payment. This means that Medicare has done a very thorough background check as to their credentials and that they are now assigned a Medicare provider number. Once they get their provider number, they are in the Medicare computer system for the processing and ultimate payment of claims.
However, once they have their provider number, physicians must make a decision as to whether or not they wish to participate in the Medicare program. The terminology couldn't be more confusing. If a doctor participates in Medicare it means that he/she accepts assignment on every patient for every service rendered. It also means that Medicare pays the doctor directly and you are billed for the remaining balance of 20 percent (in most cases).
The doctor must submit the claim to Medicare. When a doctor accepts assignment, you are only responsible for the approved amount.
If your doctor does not participate in Medicare it means that he/she does not accept assignment. Your doctor must still submit the claim to Medicare but in this case, Medicare will send the check to you and you are responsible for paying the doctor the entire charge. Incidentally, this charge is determined by the Medicare carrier who, in turn, gets the fee structure from Congress.But now we have a third scenario – the doctor who chooses not to be a Medicare provider at all. Some doctors who were once Medicare providers have decided to "drop out" of the Medicare program. This means that they are no longer in the Medicare computer system and Medicare will not honor any claims from these doctors. You must pay for all services rendered out of your pocket.
Furthermore, if you have a Medicare supplement, they won't pay either because they base their premium on what Medicare pays. A doctor who is not a Medicare provider will expect to receive payment from you and you will not be reimbursed by a Medicare supplement policy and it is questionable as to whether or not your group major medical plan (secondary to Medicare) will pay.
To further confuse the issue, we have found that the employees in a good number of physicians' offices are not familiar with the terminology. You must ask multiple questions. For example, we called to make an appointment and asked if the doctor participates in Medicare.
Answer: "No." We then asked if he was a Medicare provider. "No!" We knew that couldn't be true so we asked if they sent the claims to Medicare. "Oh yes, we'll send the claim to Medicare and Medicare will pay you and you pay us." Oh, now that is a totally different story. This doctor is a Medicare provider who does not participate or accept assignment.
You will want to make sure your doctors are Medicare providers unless you are prepared to spend a lot of money out of your pocket.
Irene Card & Betsy Chandler are both licensed insurance professionals working at MIC Insurance Services, a health insurance services company. If you have questions relative to this column or other related topics, we invite you to call (973) 492-2828, or visit our web site at micinsurance.com.
