Medicare: Choosing doctors and other providers

Choosing a medical provider can be both challenging and overwhelming for many patients. Here in the Great Land, Alaskans often travel significant distances to obtain healthcare. Medicare can help, when searching for and finding a provider. You can also save money by choosing providers who accept Medicare assignment. This last term, “assignment,” is an important one to remember, especially if you are newly enrolled in Medicare. First, a brief introduction to finding health care providers, from physicians to medical equipment suppliers. Searching for prooviders is not always easy, but help is available.

Searching for providers

You can obtain assistance over the telephone or by using the internet. Consider calling the national help line at 800-Medicare, which is also 800-633-4227. This line is open around the clock, 24 hours a day, seven days a week (except some federal holidays). Alternatively, you may call us at the State of Alaska’s Medicare Information Office by dialing 800-478-6065 or 907-269-3680. You may leave a message, and our certified counselors will be glad to call you back to help in your search for a medical provider.

When using the internet, either on a computer, a tablet, or a smart phone, begin your search by going to Medicare.gov and click the link to find care providers. This search can be narrowed by location and by the type of care, service or facility desired. An entire list of specialties can be optionally chosen to narrow your search for a provider. Once you have identified a potential provider, remember to call the office to verify if the provider is accepting new patients. A health care provider may accept Medicare, but not be able to accept new patients at this time.

Medicare assignment

The term “assignment,” mentioned earlier in this article, is an important word to remember. Different procedures, exams, tests and medical devices all are assigned prices which Medicare may reimburse. I will provide three examples on how Medicare assignment works. In the first, you go to see your doctor. This office visit is billed at $150, and the doctor accepts Medicare assignment. Medicare sets the price for this office visit at $100, and will reimburse the provider at 80 percent (or $80 in this example). Since the doctor accepts assignment, then the price is reduced to $100, and you (as the patient) owe the remaining $20 (or 20 percent of the assigned price).

In the second example, the doctor accepts Medicare, but does not accept Medicare assignment. This does not mean that the doctor’s staff gets to set the price, but instead Medicare allows the provider to bill excess charges, up to an additional 15 percent of the Medicare approved amount. So, using the same scenario, you once again go to see your doctor. The office visit is again billed at $150. Medicare still has the price for this office visit set at $100, and will reimburse the provider at 80 percent ($80). As the patient, you owe the remaining $20 (up to the assigned price) plus up to an additional $15 (or up to 15 percent additional above the assigned price of the office visit), for a total cost of $35. In both of the first two examples, secondary insurance has not been mentioned.

For the third example, and possibly the most important, another phrase, “opt out,” is used. In this scenario, the doctor has opted out of Medicare. This is not done on the second Tuesday of the month, or at the whim of the office staff. Instead, the doctor has entered into a legal agreement with Medicare (and the contracted billing services overseen by Medicare) whereby the doctor no longer accepts Medicare. Using the same scenario as above, during the doctor’s visit, the staff lets you (as the patient) know that the doctor does not accept Medicare (has opted out.) If you choose to obtain the services of this physician, then you enter into a private contract with the physician, and Medicare will not reimburse your medical claim. Additionally, Medicare supplement insurance (Medigap plans) will also not pay for the claim, neither will many other secondary insurance plans. So please be aware of both Medicare assignment and check to see if a provider has opted out of Medicare.

Pharmacy networks

Private insurance companies have established Prescription Drug Plans (PDPs) under Medicare Part D. These insurance companies have contracts established with pharmaceutical firms (drug manufacturers) and with pharmacy networks (drug distributors). You can save money by being aware of which local retail pharmacy (or your plan’s mail order option) charges the lowest price that you will pay when filling or refilling your next prescription. There are preferred in-network pharmacies, in-network pharmacies, and out-of-network pharmacies. And the price for the same prescription may be different when comparing two different pharmacies even when both are in the network contracted by the insurance company.

You can find additional details in your drug plan’s website, by using the Medicare.gov plan finder tool, or by calling our office and requesting to speak with any one of our certified counselors.

For any Medicare related questions, please feel free to contact the State of Alaska Medicare Information Office at 800-478-6065 or 907-269-3680. Our office is also known as the State Health Insurance Assistance Program (SHIP), the Senior Medicare Patrol (SMP), and the Medicare Improvements for Patients and Providers Act (MIPPA) program.

If you are part of an agency or organization that assists seniors with medical resources, consider networking with the Medicare Information Office. Call us to inquire about our new Ambassador program.

Sean McPhilamy is a volunteer and Certified Medicare Counselor for the Alaska Medicare Information Office.

 
 
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