Does anyone know if there is a limit to what a doctor can charge if he refuses to accept any insurance?

Question

I am 75 years old pay medicare premiums as well as secondary insurance premium,Now i have to get anew doctor since I am diabetic and my old doctor retired. I cannot d find any diabetic specialist who will accept insurance as my former doctors did. I made an apppointment and was told it would be $280.00 for the first visit. Seem high to me. How much would I get reimbursed by medicare and secondary insurance?

Answer 1

You have been misinformed - there is no law that states that all doctors can only charge 15-20% above Medicare rates.

A doctor who doesn't accept insurance can charge pretty much whatever he/she wishes.  $280 probably does seem a little steep if that's only a consultation fee (you didn't indicate what type of visit it was or if any tests, etc. were included in that figure).  But, if people are willing to pay that fee, then presumably the doctor is offering a service that isn't available elsewhere.  

Do you live in a rural area with limited specialists?  In most urban and suburban areas, there should be a variety of diabetic specialists to pick from.  I do understand, of course, that rural areas have fewer specialists available.  If you think that fee is too steep for your budget, you may want to shop around for other specialists.  Even if they don't take your insurance, you still might find one with fees that are closer to your budgeted amounts.  (Though ideally you'd find a doctor who will accept Medicare and/or your secondary.)

As for what you'll get reimbursed by Medicare and secondary insurance...you'll get reimbursed up to the Medicare allowed amount.  The secondary is not going to cover the difference between Medicare's allowed amount and the doctor's billed charge.  (That's not the purpose of secondary insurance...secondary insurance helps to cover the Medicare deductibles and coinsurance.  It would be a rare secondary policy that would cover any balance billing amounts.)

Answer 2

A doctor who is not accepting insurance can charge whatever the market will bear.  As far as I know, there is no law limiting how much a doctor can charge.  It is called "free enterprise", which is based on "supply and demand".  If no one is willing to pay him, then if he wants to stay in business he will have to lower his price.  This system has been found to work fairly well.

Part of the problem is that Medicare payments have not kept up very well with the real world.  The doctor usually doesn't get anywhere near as much compensation from a Medicare patient as he does from a patient with private insurance or who pays cash.  And, Medicare does not allow the doctor to accept the Medicare plus extra money from the patient.  If the doctor accepts Medicare for that patient, he must charge only what Medicare says -- he can't take anything else from that patient.  That's probably why you're having trouble finding a doctor that takes Medicare.  (Put yourself in his shoes.)

That's the problem.  Don't ask me what the solution is, healthcare costs are one of the most hotly debated questions in the political world right now. I wouldn't be surprised if lots of people jump in here with their opinions on what is the best system to use.

Answer 3

You should find a doctor who will accept your insurance.

Answer 4

If the doctor is not a Medicare approved doctor he can charge whatever he wants. Medicare will not pay anything. Your secondary will not pay anything.

If the doctor is a Medicare approved doctor and he accepts assignment he must only charge what Medicare will approve. Medicare will then pay it's share and your secondary will pick up the balance.

If the doctor is a Medicare approved doctor and he does not accept assignment he can charge up to 15% more than Medicare will allow (called Part B excess). Again, Medicare will pay it's share. What the secondary will pick up depends upon what type you have. If you have a Medicare supplement Plan F, I, J, or high deductible J it will pick up the balance of what Medicare doesn't pay, including the Part B excess. If it is a Medicare Supplement high deductible Plan F it will pick up the balance to the Medicare approved amount and 80% of the Part B excess. All other supplement plans do not cover excess Part B costs.

Answer 5

There are 3 possibilities.

1. You visit "participating" physicians, who are approved by medicare. These doctors accept medicare assignment. This means they agree to medicare's allowable amount, and agree to charge you the 20% ccoinsurance for part B services. They also file medical claims on your behalf. This is called "accepting assignment"  You can locate these doctors using the provider directory online or calling medicare.   http://www.medicare.gov/Physician/Search...

2. You visit a physician, who does not accept assignment, but agrees to treat medicare patients. This type of doctor may bill you in excess of medicare's allowed amount; but no more than (usually)15% PLUS your normal part b coinsurance of 20%. They may file claims on your behalf, but it is not required. They may require you to fill out/sign an ABN.

3. You visit a doctor who does not provide services through the medicare program. They have intentionally opted out of the program entirely. This type of service will be paid for entirely by the patient, typically up front, & has no limiting charge. Medicare refers to this as a "private contract agreement"  There's a brochure on medicare's website about this.  http://www.medicare.gov/Publications/Pub...    

The doctor can charge as much as they want. Private insurance & medigap RARELY pay for these services.

Also, when using the provider directory on medicare's website, I found more than 80 endocrinologists within 20 miles of Bethesda. Your best bet is finding a doctor who accepts medicare. Good luck.

Answer 6

I recently had an office visit that cost that much as well. The doctor was one of the top experts in the country for my problem.  He was set up to take cash payments in advance, and I doubt he would have taken my insurance