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Mary Shomon

Why Some Doctors Don't Accept Medicare or Insurance

By April 24, 2010

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A reader wrote to me recently, to complain about the policy of the one of the doctors I've interviewed here at the About.com site, who treats thyroid and hormonal imbalances. The reader had contacted the doctor, and was furious after learning that the doctor does not accept Medicare patients.

That doctor is not alone, however. An increasing number of doctors are opting out of the Medicare system, including many of the specialists, internists, and integrative physicians who handle thyroid, hormonal, fatigue, and immune system problems. In fact, many of these doctors don't accept Medicare, and also do not participate in any private insurance programs at all. Their patients need to pay out of pocket, up front, and file themselves to get whatever reimbursement is available under their coverage.

Why are more doctors opting out of Medicare and insurance programs? There are a number of reasons.

  • Medicare regularly cuts the rates of reimbursement, which means doctors earn less for office visits and various procedures
  • There is a longer delay than ever before for doctors to get reimbursements from Medicare
  • Medicare has a very convoluted, bureacratic process that allows some tests and treatments, refuses to pay for others, and limits how a doctor can practice medicine
  • Private insurers set low reimbursement rates for various services and treatments, rates that may not even cover a doctor's overhead.
  • Insurers often systematically make reimbursement deliberately difficult, complicated and time-consuming.
  • When reimbursement is approved, payments from insurers can be extremely slow to reach the physician.
  • Doctors may need additional staff to handle the extra paperwork, phone calls, resubmissions, and negotiation with insurance companies.
How do you find a doctor who accepts Medicare? The Medicare Web site provides a list of enrolled doctors. You would need to contact a doctor to determine if he/she is accepting new Medicare patients, however, as many don't. Some patients choose to use an urgent care center, which are also known as "walk-in clinics," "stand-alone clinics" -- or, derogatorily, sometimes called a "doc-in-a-box." There are more than 18,000 of these clinics in the U.S., and the majority of these centers do take Medicare patients. The American Academy of Urgent Care Medicine has a directory of urgent care centers online, by state.

As for doctors who will accept your insurance, most insurers will provide you with a directory of participating physicians, and may even assist you in getting an appointment or signing up as a new patient.

Learn More About Medicare and Insurance Issues, and Why Doctors Are Opting Out

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April 25, 2010 at 1:39 pm
(1) inchoate but earnest says:

Mary, great article, kudos – but what do you make of AAUCP reporting that there are 18,000+ urgent care centers in the US, but their online locator only including 3,900 of them? Not all of those they list are AAUCP members, so that’s not the determining factor. (& to be useful, they should really include phone # & hours info for those locations they DO report).

It raises the question: how good is their data, really?

April 30, 2010 at 3:54 am
(2) Elle says:

I work for a group of doctors who do not take insurance or Medicare. I have to say I was not a big fan of doctors based on my own medical experiences. When I was first hired, I wondered why these doctors did not take insurance or Meidicareówere they greedy or too alternative or what? I learned differently–What I have learned is that, as opposed to doctors who take insurance, these doctors continually strive to improve therapies, work like detectives to help their patients and spend about 4-6 times more time with their patients. They are passionate about what they do.

They all took insurance and Medicare in the past and became very frustrated, as the insurance model rewards uncaring doctors who do the minimum and are able to see as many patients as they can. I have learned that two-thirds of Medicare and Medicade reimbursements are less than the cost of the service. Thus, the only doctors who take such insurance do so because they provide the minimum care, if you are lucky. Most doctors donít care to learn new ways to help patients; they keep doing what they learned in medical school. When patients go back to their primary care physicians dramatically better, most doctors donít care to call and the ones that do usually respond with that would take to much time with the patient and is too complex to do.

These doctors spend so much time outside of seeing patents going over studies at an intraoffice journal club, working together for difficult patients and are passionate about medicine. I have to say most doctors are just going through the motions. When you look at it, they actually bill much less per hour (about $400) compared to insurance doctors who bill at much higher rates seeing 4-6 patients per hour. These doctors have to provide much better care or the patient does not keep coming back. Insurance doctors will just be sent more patients as long as the insurance company rates them as good, which means not costing the company too much money. They do this by doing minimal tests and not recommending more expensive therapies (even though they may be more beneficial to the patient).

I just wanted to give a view of what I learned, because I felt as that patient did before I learned what was really going on. Some of you may disagree, but this is what I have learned.

April 30, 2010 at 10:36 am
(3) Jenine says:

I have to agree with Elle, coming from a patients point of view. I seem to get the best medical care when I pay out of pocket. I have gone through two years with hypothyroid symptoms and I saw several doctors covered under my insurance that all told me there was nothing wrong with me. None seemed concerned about my symptoms, They all looked at the lab report (which anyone could do) and said everything was normal. I almost gave up and than decided to try an alternative doctor which I knew I had to pay out of pocket but I was desperate for help so I tried him. He diagnosed me and helped me feel normal again. Over the years I have gone back and forth between doctors I payed out of pocket (when I could afford to) and doctors covered under my insurance and I seemed to get the best care from the doctors I payed. The other doctors made me feel like I was in a fast food restaurant. One doctor recently thought that I got my Armour (I’m on Nature-throid now) medication from GNC.

April 30, 2010 at 10:36 am
(4) Anne says:

I have recently learned from 2 medical providers that if you make a small mistake in documenting a patient’s treatment you have to return all the moneys for the entire treatment of that patient to government programs like Medicaid and Medicare, not just the part of the treatment which was improperly documented. Everyone makes mistakes. The auditors will enforce this extreme penalty if every jot and tittle are not correct. This policy is not regarded as a fine, but requiring repayment of moneys which the provider should not have received. That’s double talk: it’s really an exorbitant fine.
I think any sane person would avoid being involved in such a risky arrangement.
I conclude there must be an awful lot of doctors out there who are more interested in helping people as much as they reasonably can, disregarding potential financial ruin.

May 1, 2010 at 12:25 am
(5) rcp says:

Yes, please talk to your Representatives & Senators. Medicare generally pays about 45% — or less — of “real world” medical fees; if the physician makes ANY error in billing — and we’re talking about, for example, billing $100.49 versus $100.47 — the physician is subject to a $2,000 civil fine PER BILL sent; if the feds choose to get nasty the assumption is that ALL similar bills have the same error {“a systematic program of fraud”} and thus the RICO statutes {as in “organized crime”} are invoked calling for TRIPLE DAMAGES — all of which together can push a fine into the million dollar range very quickly. In my state, Medicaid generally pays about 15% — or less — of “real world” medical fees IF the physician gets the bill sent in before the state runs out of “theoretical” money for that calendar quarter; I say “theoretical” because in my state physicians, pharmacies, and hospitals currently are owed in excess of FOUR BILLION dollars by the state government — even though those whose bills come in late in the calendar quarter are alloted ZERO payment.

The whole situation is pathetic — yet the new healthcare reform bill will be moving MILLIONS more patients on the bankrupt Medicaid roles.

It gets worse: while it technically is against Federal law for a hospital to treat a “Medicare eligible” patient — who might be a 20 years old disabled patient — without billing Medicare, in 1993 — yes, 1993 — a Federal District court ruled that this point was moot because Congress never published regulations governing prosecution — and STILL has not done so — most likely on purpose — so that no one exactly what would happen if a hospital (or a physician, for that matter) did try to operate openly outside of Medicare.

I repeat, the whole situation is pathetic. I repeat, talk to your Represenatives and Senators. Promised treatment via Medicare and Medicaid is on the path to becoming non-existent for all intents and purposes.

May 4, 2010 at 6:56 am
(6) Ciara says:

How is it even LEGAL, let alone ethical (which it clearly isn’t) for an insurance company ESPECIALLY a state backed one, to dictate to a doctor as to what procedures or surgery to do.
Basically it seems to be that you have an insurance exec who is completely medically unqualified, teling a medically qualified and expericed doctor how they should practise medicine??>

May 4, 2010 at 6:57 am
(7) Ciara says:

How is it even LEGAL, let alone ethical (which it clearly isn’t) for an insurance company ESPECIALLY a state backed one, to dictate to a doctor as to what procedures or surgery to do.
Basically it seems to be that you have an insurance exec who is completely medically unqualified, teling a medically qualified and expericed doctor how they should practise medicine??
How on EARTH is that permitted?

October 15, 2011 at 12:31 am
(8) Paul Mulcahy says:

As a 100% disabled US Army retired patient, the military hospitals in San Antonio tell you they are taking only active duty troops or those who are “freshly wounded” (as one sergeant told me); the VA hospital has a 6-24 month waiting list, depending upon what kind of care you need; and the local doctors, which is who the military tell us to go to, don’t take Medicare or Tricare because of paperwork and that they don’t pay enough. It took me seven months to find my last psychiatrist after being told by the psychiatrist I had that Medicare and Tricare don’t pay enough; when I found another psychiatrist, I only got to see him for five months before he moved to a practice that also doesn’t take Medicare or Tricare. Who knows when I’ll see another psychiatrist? I’m seeing a rheumatologist on Tuesday, after a five-month search.

What ever happened to “First, do no harm”? It seems to have been replaced by “First, make more money”.

September 3, 2013 at 11:32 am
(9) avibes says:

It is a federal crime for a doctor to accept kickbacks from doctors to which they referrals. Easier for them not to deal with Medicare/Medicaid/etc patients

September 3, 2013 at 12:04 pm
(10) Mary says:

Check out EFT online and maybe you can assist yourself for little to no money required.

Gary Craig’s website, emofree.com, has useful information and samples of people who have been assisted by practitioners.

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