What to do when your physician leaves Medicare program

Medicare provides health insurance coverage to nearly 20% of the U.S. population.

It also is an income stream for physicians. Yet reimbursement rates and demanding paperwork may create burdens on practices, especially smaller ones that may struggle to balance the time they spend on administrative tasks versus patient care.

Kaiser Family Foundation studies have found that for physician services, private insurance paid an average of 143% of Medicare rates.

While an overwhelming number of medical practices accept patients with Medicare insurance, 1% of all nonpediatric physicians formally opted-out of the program in 2023, according to the foundation. Psychiatrists accounted for the largest share, at just over 40% of those who left.

As a patient, discovering that your trusted doctor has opted out of Medicare is a disruption. You'll now need to search for another provider within the network or consider additional out-of-pocket costs.

Kelly Blackwell, a certified senior adviser and registered nurse, counsels individuals across the United States — including in Northwest Indiana — on Medicare decisions. She has served as a contributing expert to online Medicare resource sites and says any big change in life is a good time to take stock.

"It's a good chance for someone to remember they are a consumer of health care and they are in a position where they can be educated and empowered about their choices moving forward," she said.

Typically, patients will have two choices if their doctors opt out of Medicare: Stay with their provider and pay out of pocket or find a new provider.

Pay out of pocket

When physicians opt out of Medicare, they may enter into private contracts with their patients, Blackwell said. The provider and the patient cannot bill Medicare for reimbursement, so bringing in a financial planner to help you assess how these new costs affect your budget can offer benefits.

"As seniors, we spend 10-15% of all of our monthly expenditures on health care, so it would be helpful to figure this out with your financial adviser as a line item," she said. "You may have an HSA (health savings account) that you can use as well."

While this option isn't feasible for many patients, some physicians may be willing to lower their rates, especially for an established patient.

"If you do self-pay, a lot of times there is a discount that comes with it," Blackwell said. "You'll need to talk with an office manager and financial adviser since if you're paying out of pocket, you really need to be a good consumer and consider how much services cost."

Patients also may be notified that their physicians are now non-participating providers. Practitioners who receive payments from Medicare must enroll as a Medicare provider, though they may agree to be a participating provider or a non-participating provider.

Participating providers sign a participation agreement with Medicare and agree to accept Medicare's fee schedule amounts as payment in full for any Medicare-covered service.

Most physicians who bill Medicare are participating providers. However, non-participating providers physicians can still accept Medicare patients. Those health-care professionals can choose whether to take Medicare's approved amount on a claim-by-claim basis.

While participating providers are paid the full Medicare-allowed amount, non-participating providers can take only 95% of it. However, non-participating physicians can charge patients up to 15% more than the Medicare-approved amount.

If your doctor becomes a non-participating provider, you'll likely have to pay the difference between his fee and the Medicare-approved amount. Keep in mind that you may also have to pay the entire bill during your office visit with you or your provider submitting a claim to Medicare.

Patients can also use a hybrid approach to their care by visiting their current physicians for treatments and heading to urgent care or public health clinics for others. Urgent care facilities and health clinics are more likely to accept Medicare.

However, Blackwell notes that this approach can limit your face-time with the same team of health-care specialists treating you.

"It's a strategy, but you may miss out on the benefits of preventive health, which as you age, probably isn't a good strategy," she said.

Find a new physician

The other alternative is to find a new doctor.

"If they have a good relationship with their physician, my guess is that the physician would make a recommendation," Blackwell said. "If not, ask for a recommendation."

This is a good time to consider what matters most in health care before searching for a new doctor, she says.

"Most people begin to have an idea of what matters most as far as ease of referrals, ease of seeing a specialist or being able to get the services they need when they need them," she said. "You know what your most pressing health concerns are."

Family and friends can provide insight into other physician qualities you may seek, Blackwell said.

"You may want a knowledgable doctor, but one who has a set of soft skills," she said. "It's a good time to think about what attributes and qualities are important to you."

Jenifer Groth, deputy commissioner of Communication and Personnel with the Indiana Department of Insurance, says if consumers are enrolled in original Medicare, they can check to see whether a new provider accepts Medicare at medicare.gov.

"On the Medicare website, there is a tool to search for physicians and other health-care providers that participate in Medicare," she said.

Barbara Rossi, insurance consultant and senior promise coordinator with Franciscan Health, says community resources also are available to help patients who may find themselves in need of a new doctor or help navigating the Medicare system.

Franciscan Insurance Services is one of those resources that helps patients find policies that meet their needs. In her work with the service, Rossi says she has helped individuals locate doctors approved under their plans.

"It's a great service that helps the senior community," she said.

Medicare Advantage

Stephanie Piessens, resource connections supervisor for Northwest Indiana Community Action, says doctors can leave Medicare Advantage Plans at any point. Medicare Advantage Plans, also known as Part C, are a way for Medicare beneficiaries to receive their Part A and Part B coverage through private insurance companies approved by Medicare.

"If the client has an HMO, they will 100% have to choose a new doctor," Piessens said. "HMOs will only pay toward doctors that are signed up in their network. They can contact the plan and ask for a listing of providers in their area."

Those lists often include ratings submitted by plan members who have seen those doctors and may include information such as wait times, appointment availability and bedside manner.

"They can also check that listing to see if the doctor has privileges at the hospital the client prefers," Piessens said.

If individuals have a PPO Advantage plan, they may not need to change doctors, even if their doctors become "out of network."

"PPO plans have a network of doctors that they prefer to work with," she said. "Clients on PPO plans who use in-network doctors have lower co-pays. PPOs will, however, pay toward doctors out of network, just at a lower rate."

Patients on PPO plans may also face higher annual deductibles and co-insurance requirements if they stay with an out-of-network doctor, depending on the Advantage plan.

As you transition to a new physician, Blackwell recommends making sure you have access to all your medical records.

"Be aware of your own history so if you go to see someone new, you don't have to start from scratch," she said. "That's true whether your doctor opts out of Medicare or you're moving to a new location."