Medicare: MD 'opted out'

chisueNovember 3, 2008

My hip surgeon 'opted out' of Medicare. How does this differ from an MD who 'doesn't accept Medicare assignment'?

I have filed with Medicare myself, attempting to get some portion of the surgeon's charge reimbursed. My first claim was rejected because I 'failed to list where the operation was performed'. (Although there was no place on the form that asked that question.) I re-submitted a month ago, attaching the statement of bills and payments and codes for all related procedures as well as his. Nothing back yet.

Medicare paid on all the peripherals to this surgery -- hospital charges, anesthesiologist, orthopedic assistants, pre-op exam and tests, post-op home visits by RNs and PTs.

I would hope to get reimbursed something of the cash I paid the surgeon. I went with him because he is the top MD in the Chicago area for hip replacement and he did my other hip. He is credentialed, qualified, etc. and Medicare would have paid *something* to any other surgeon.

When I see an ENT who 'doesn't accept Medicare assignment', I pay the fee; his office submits to Medicare; I receive a partial refund of what I paid. I don't see how 'opting out' should mean a different result for the patient.

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I may be incorrect, but I think that when a doctor decides to "opt out", it means that he is no longer seeing ANY Medicare patients.

"Accepting Assignment" means that he will accept a lower amount in order to get the check sent directly to the office. If he doesn't accept assignments, the check goes to the patient and often is spent and the doctor has to wait for payment.

The problem is that when a doctor see a Medicare patient, he agrees that he will accept the Medicare Approved Amount as the full amount of the bill for services. Medicare then pays 80% of this and the patient(or insurance) pays the remaining 20%. the unapproved balance has to be written off.

The problem is that the Approved Amount is so small in many cases, that the doctor does not get enough to pay for the service. Or some pencil pusher decides that the service/test or whatever wasn't needed, in which case, the doctor gets zero. More and more doctors with busy practices are refusing to see Medicare patients.

I worked in various MDs offices and my son is a doctor. The amount "approved" by Medicare is often ridiculous.

I had an MRI of my head done. The doctor was looking for a brain tumor as nothing else seemed to explain why I was having trouble walking. Medicare refused to pay a single dime because someone decided that I didn't need an MRI. I didn't have to pay because the doctor had failed to warn me IN WRITING that they might not pay. The entire amount of over 800 dollars was written off. Makes sense, doesn't it, that someone sitting at a desk knows more about it than my doctor.

    Bookmark   November 3, 2008 at 8:24PM
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agnespuffin -- I think you meant to say that some MD's have 'opted out' of Medicare or have 'refused to accept Medicare assignment', not that they won't treat people over 65, virtually all of whom have Medicare. Or, are you really saying they won't accept patients on Medicare at all?

I understand the 'why' of it. Medicare pays too little for most services -- and too much for extreme, end-of-life technology! This is one reason med students don't go for 'Family Practice', but for the big bucks specialties.

I'm trying to understand the difference TO ME AND MY POCKETBOOK between: 1) 'refuse to accept assignement' (where Medicare refunds some of the fee I pay) and 2) 'opt out' (where I get...nothing back?).

If Medicare will pay (for instance) 80% of $2,000 for a hip replacement to an MD who accepts assignment, why won't Medicare reimburseme me that amount after I have paid the full fee?

If Medicare sends me a partial refund after I pay an MD who does not accept assignment, how is that different from refunding to me after I pay an MD who has 'opted out'?

    Bookmark   November 4, 2008 at 10:22AM
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"Accepting Assignment" has to do with how the payment is made. If the doctor Accepts Assignment, he accepts a lower approved amount in return for getting the check made out to him and sent directly to his office. The patient is then billed only for the 20% balance.

If he does NOT Accept Assignment, the approved amount is a little more and the check is made out to the patient and is sent to the patient. The doctor bills the patient directly for the full APPROVED amount.

You should never pay a doctor before you know what Medicare will approve as it often changes. If you overpay, you may never know that the doctor is carrying a credit balance on your account. It's not the doctor's fault, it's more the fault of the insurance clerk or the office manager.

A doctor has to apply for a Medicare number and be approved to see Medicare patients. And he MUST bill for ALL of them. To opt out means that he agrees NOT TO SEE MEDICARE PATIENTS, as he cannot bill either them or medicare for the service. At least that was the way it worked a few years ago. I don't think it has changed. He can't bill for just some of his medicare patients. He has to bill Medicare for ALL of them. He may accept assignment on some of them, and refuse assignment on others, but he has to bill Medicare for all of them, and he has to accept the approved amount as the entire charge and write off the unapproved amount.

For example. Let's say that the usual fee for a service is $50.00. Medicare might approve it for 25.00. If he accepts assignment, the 80% (20.00) goes directly to him. If he doesn't accept assignment, Medicare may approve it for a little more, maybe for 28.00. 80% of 28.00 is 22.40, the patient gets a check for the 22.40 and the doctor can then bill for the entire 28.00. But NOT for the full amount of 50.00

A doctor that no longer wants to see (and accept Medicare terms) may opt out of the program.

I think we may not be talking about the same thing when we speak of Opting Out of the program. It's not the same thing as not accepting assignment. As far as what it means to your pocket book, that's another thing. The approved amount may be 25.00 today, and Medicare may change it to 18.00 tomorrow or 26.00 at another doctor's office. I think that sometimes it depends on how fancy and detailed the diagnosis is. High Blood Pressure gets X amount of dollars, If the doctor also adds that you have rhinitis ( a runny nose)the approved amount might be more. It would depend on who was handling the claim.

Dealing with Medicare and it's thousands rules and regulations is a royal pain in the you-know-what. I expect that more and more doctors with full patient loads will be opting out. They don't need the hassle. That means that the over 65 patient will be seeing the doctor that hasn't built up a good practice yet.

    Bookmark   November 4, 2008 at 12:08PM
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agnespuffin -- Thank you. Now I get it. It seems draconian: either see Medicare patients or see none! I don't see how that can last with the burgeoning numbers of Seniors. Something is going to have to 'give'!

I appreciate that you would take time to explain this so well. Guess I won't be getting anything back from my $7K.

    Bookmark   November 4, 2008 at 2:09PM
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Oh, dear! That is a lot. Have you gotten an EOB statement from Medicare saying that they have paid the doctor? You may not have yet as they aren't as quick about doing it as they used to be.

I would call the Doctor's office and ask if they have received any payment. If it's been over six months and they still haven't, it could be that the claim was denied. Let's hope not.

Now, just watch. There will probably be someone posting to say that all that has been changed and everything is different.

You are right about one thing, Medicare is going to be a big mess soon. It's got to be cleaned up and straightened out somehow. You wouldn't believe the crap that the medical practices have to wade through just to keep up to date on changes..

Because it is so messed up, it is easy to overlook certain rules and then the doctor finds himself in hot water with fines and penalties. The System is also overloaded with the sheer number of claims. This has opened wide the doors for fraud and overbilling. The worse thing is, I think, is the the doctor may be 100% honest and is trying to do the right thing, but his insurance clerk is somewhat underhanded and has no problem with questionable billing practices and coding. Anything goes if Medicare will be more apt to pay.

    Bookmark   November 4, 2008 at 2:39PM
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No, no, that's not quite right. *I* paid the surgeon $7K and *I* am filing myself to try to get something from Medicare -- like maybe the amount of the 'Medicare assignment' for Chicago area surgeons doing hip replacements.

Yes, it is a lot of money. If he was not the top-rated guy in the area and if I had not used him for the other hip...back before he 'opted out'...I wouldn't have done this. It could have been worse; if I were obese, it would have been $9K!

    Bookmark   November 4, 2008 at 5:12PM
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Hi chisue, I answered your question on Home Finances. Opting out is so confusing to people, it is the responsibility of the physician to explain to his patients what it means. Many doctors are opting out of Medicare because of poor payment. I will repeat what I wrote on the other post in case other people run into what you did.

When a doctor opts out of Medicare it means he cannot bill Medicare for treating a Medicare patient. He will bill the patient directly. This is a contract between the doctor and patient. Medicare does not have anything to do with this. Your contract with the doctor is a private contract. Medicare will not reimburse you if you choose to do this.

Medicare penalizes the patient for seeing a doctor who opts out of Medicare. You will not get reimbursed and he won't get paid by them. You are responsible for the bill.

At least you had a doctor you chose, not dictated by an insurance company. More and more doctors are dropping out of Medicare. This does not mean they can't treat Medicare patients. It just means his bill goes to you. You are responsible by choosing him.


    Bookmark   November 9, 2008 at 12:07AM
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