Understanding Medicare Assignment When Looking For a New Provider

Let’s face it, finding a new provider can be difficult. From long wait times and reading reviews to getting recommendations, you never know what the actual experience feels like until you’ve had your initial consultation. On top of that, figuring out whether a provider takes your Medicare insurance and knowing what you’ll pay can often seem like a game of the Price is Right.

Medicare is the federal health insurance program for individuals who are 65 or older, have certain disabilities, or have end-stage renal disease. While most healthcare providers accept Medicare, it’s important to understand the three network categories they fall into before choosing a new provider.

The Provider Doesn’t Take Medicare

Although most providers still take Medicare, many primary care providers and mental health providers are slowly transitioning to cash-based practices. If your provider does not generally take Medicare insurance, you’re out of luck. Even if your Medicare plan (whether it’s a PPO or fee for service) allows you to see out-of-network providers, they must, in general, have to accept Medicare to be compensated as out-of-network. If your provider does not take any Medicare insurance, you’re left with paying the total bill as the only option.

The Provider Takes Medicare but Doesn’t Take Medicare Assignment

Just because a provider accepts Medicare doesn’t mean that you won’t receive any surprise charges. By accepting Medicare, the provider agrees to see Medicare patients and will receive some form of compensation from Medicare. However, there’s an additional caveat: Medicare assignment.

Medicare assignment is when a provider not only takes Medicare but agrees to what Medicare decides as reasonable payment. For Original Medicare, providers taking Medicare assignment will just bill the Medicare negotiated allowable fee. For Medicare Advantage plans with networks, providers who agree to the plan’s fee structure will simply charge the co-pays on your plan.

However, if a provider does not take Medicare assignment, then you as a patient could potentially be billed excess charges equivalent to up to 15% of what Medicare would pay.

For example:

• Medicare lists an office visit as worth $100.

• Part B covers 80% of the cost.

• Your cost would be 20% or $20 in this case. (if you have a supplement, this cost may be partially or fully covered)

• If your provider doesn’t agree to the assignment, they can charge up to $115 (15% extra) for the visit.

• Part B will only cover 80% of the $100, meaning you’re responsible for not only 20%, but also the extra 15% excess charge.

Some supplemental policies will cover the surcharge while others will not. If you have a Medicare Advantage plan, you’ll have to check with your plan if an out-of-network provider will bill excess charges.

There are also states where excess charges are not allowed. These are Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont.

In these states, if the provider takes Medicare, they have to accept Medicare assignment.

The Provider Takes Medicare and Takes Medicare Assignment

If your provider takes both Medicare and Medicare assignment (more than 90% of providers), then your co-pays will be simply the fee that your supplement or Advantage plans dictate.

Although most Medicare providers take Medicare assignment, it’s always prudent to double check when choosing a new provider. The easiest way to ensure that your provider accepts Medicare and Medicare assignment is to ask them directly or check on the Medicare website.

In addition, it’s important to check whether your provider is in-network or out-of-network for your Medicare Advantage plan. Medicare Advantage plans are offered by private insurance companies and can differ from plan to plan. If you choose an Medicare Advantage plan, you should double check is a network of providers near your area.

How to Find Providers Who Accept Medicare Assigment 

So, now that we understand the different network categories that providers can fall into, let’s dive a little deeper into how you can ensure that you choose a Medicare provider who not only takes your insurance but also takes Medicare assignment.

The first step in finding a new Medicare provider is to do your research. There are a variety of resources available that can help you find a provider who not only takes Medicare but also takes Medicare assignment.

One great resource is the Medicare.gov Physician Compare tool. This tool allows you to search for providers based on specialty, location, and whether they take Medicare assignment. You can also read reviews from other patients, which can be a valuable source of information when making your decision.

Another great resource is your Medicare Advantage plan or Medigap insurance provider. These plans often have a provider network that you can use to find providers who accept Medicare assignment.

If you’re still having trouble finding a provider who takes Medicare assignment, consider asking for recommendations from friends or family members who are also on Medicare. They may have already gone through the process of finding a provider and can provide valuable insight.

Once you’ve narrowed down your list of potential providers, it’s important to call and ask whether they take Medicare assignment. You should also confirm that they accept your specific Medicare plan, as some providers may only accept certain plans.

It’s also a good idea to ask about any potential surprise charges or excess charges that you may be responsible for. While most providers take Medicare assignment, there are still some who do not. It’s important to know this ahead of time to make an informed decision about whether to see that provider.

In addition to asking about charges, it’s important to ask about the provider’s experience and qualifications. You should feel comfortable with your provider and confident that they have the knowledge and skills necessary to provide you with the care you need.

Finally, it’s important to remember that finding a new Medicare provider can take time. Don’t be discouraged if you don’t find the perfect provider right away. Keep searching and don’t settle for a provider who doesn’t meet your needs.

In conclusion, understanding Medicare assignments is essential when looking for a new provider. By knowing the different network categories that providers can fall into and doing your research, you can find a provider who not only takes your Medicare insurance but also takes Medicare assignments. This will help ensure that you don’t receive any surprise charges and that you can receive the care you need without breaking the bank.