Comparing the Medicare participation categories and fee rules.

Comparing the Medicare participation categories and fee rules.

Medicare assignment is a doctor’s agreement to accept Medicare’s approved amount as full payment for a service. A doctor who accepts assignment can only charge the patient the normal deductible and coinsurance, which the Medigap plan covers. They can’t bill anything extra.

Yes, a doctor can accept Medicare without accepting assignment. There are three types of doctors:

1. Participating doctors always accept assignment. They bill Medicare directly, and the patient never pays an excess charge. This is most doctors.

2. Non-participating doctors are enrolled in Medicare and see Medicare patients, but they don’t always accept assignment. These are the doctors you’re asking about.

   • They can decide case by case whether to accept assignment.

   • When they don’t accept it, they can bill up to 15% more than Medicare’s approved amount for them. That extra is the excess charge.

   • The patient may have to pay the whole bill up front and wait for Medicare to reimburse its share.

   • They still have to submit the claim to Medicare, so Medicare and the Medigap plan still pay their shares.

3. Opted-out doctors don’t work with Medicare at all. The patient signs a private contract and pays the full bill, and neither Medicare nor Medigap pays anything. This one catches people off guard.

What it means for your clients:

• Plans F and G cover the excess charge from a non-participating doctor, so the client owes nothing extra.

• Plan N doesn’t cover excess charges, so the client pays the extra amount, which is at most 15%.

• No Medigap plan pays anything for an opted-out doctor.

What clients should ask before a visit: “Do you accept Medicare assignment?” Asking “Do you take Medicare?” isn’t enough, because a non-participating doctor can honestly say yes. Clients can also look up any doctor on Medicare’s Care Compare site at medicare.gov, which shows whether the doctor accepts assignment.