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health / Stones & Bones / volume 10 number 2, February 2008 DOSE OF REALITY Are you on Medicare but having a hard time finding a doctor who will take you? What can you do about it? Sadly, the answer is not much. It’s your doctor’s choice, not yours. This is a problem facing an increasing number of older Alaskans because more and more of our doctors are going on strike against Medicare patients. Although most doctors in the United States do treat Medicare patients and get paid by Medicare and supplemental insurance companies, more and more of them are striking against their older patients by opting out of Medicare or refusing to take new Medicare patients. A doctor has three choices. He or she can be what is called a Medicare participating provider, who agrees to be paid at Medicare allowance rates for all services to those Medicare patients he treats. For each service provided, the doctor receives from Medicare 80 percent of the Medicare allowed amount, and the patient or his supplemental insurer pays the other 20 percent, but no more. The provider agrees to bill Medicare for his services to Medicare patients, and Medicare agrees to bill any supplemental insurer for the 20 percent of the allowance not paid directly by Medicare. The doctor does not have to accept all Medicare patients who might want his services; if he chooses to he can limit the number of Medicare patients in his practice. A second doctor’s choice is to become a nonparticipating Medicare provider. He receives payments for his services in two ways. If he accepts a patient “on assignment,” he bills Medicare and receives payment directly from Medicare. However, the amount of the Medicare allowance is then reduced to 95 percent of the normal allowance. He receives from Medicare 80 percent of the reduced allowance and from the patient the other 20 percent of the reduced allowance. The Medicare non-participating doctor also has the option not to accept assignment for a Medicare patient. If he does that he still submits a claim to Medicare but receives payment from the patient, and then Medicare reimburses the patient afterwards. However, he is allowed to bill the patient for 115 percent of the reduced Medicare allowance. The overall result is that the doctor can receive a total payment amounting to 109.25 percent of the full Medicare allowance, the patient or his supplemental insurer paying a larger share of the cost than if the doctor were a Medicare participating provider. Like the Medicare participating provider, the nonparticipating doctor can refuse to accept new Medicare patients. The third option for the doctor is to opt out of Medicare altogether to become what is called a private-pay contractor. He agrees to accept no pay from Medicare for any except emergency services he might happen to give to Medicare patients. He receives all payment from the patient, and he can charge any rates he chooses. If the Medicare patient has supplemental insurance, the supplemental insurer will refuse to make any payment to a private-pay contractor whatsoever, and may also refuse to make payment to a nonparticipating Medicare provider. The patient is stuck with the whole bill, and that bill may be for amounts far larger than what Medicare would pay. This all seems very unfair to the person who has worked much of his life to become a Social Security beneficiary and receive the medical benefits this status provides, is currently paying for additional Medicare coverage, and paying as well as for supplemental insurance. All that investment is suddenly worthless if the patient’s doctor opts out of Medicare and the patient cannot find another doctor willing to accept him as a Medicare patient. Doctors cite two main reasons for going on strike by refusing to accept Medicare patients or opting out of Medicare. One is the onerous task of filing the complex Medicare claims for reimbursement to the insurance companies who contract with Medicare to process the claims, and the slowness of payment for those claims. Another is the level of payment on Medicare claims, cited as being too low by some doctors. A specific example of the consequences of the doctors’ strike is what happens to a Medicare patient in interior Alaska seeking the services of a dermatologist. Two dermatologists practice in Fairbanks. One is a Medicare participating provider who is now accepting no new Medicare patients, and the other has opted out of Medicare. The Medicare patient cannot receive services from the former, and can only receive care from the latter if he pays an up-front bribe in cash—at whatever rates this doctor chooses. The patient’s Medicare and any supplemental insurance are worthless unless the patient seeks care in Anchorage, Seattle, or elsewhere where apparently not all dermatologists have as yet gone on strike against Medicare patients. We can expect the situation to get worse because, as the Anchorage Daily News recently reported, Alaska is experiencing a shortage of doctors, especially primary care physicians. The shortage is hitting Medicare patients the hardest because they are the first to be denied services by the doctors who have chosen to limit their clientele or have opted out of Medicare. If you find yourself on the short end of this stick, it’s time to give serious thought to getting more of your medical care outside of Alaska. Even considering the cost of a ticket to Seattle, you may save money by going there or elsewhere. These days, Seattle is only three hours away. For Alaskans needing elective health care, Whitehorse, Vancouver, and Bangkok are other possibilities worth considering. It’s a sorry state of affairs, but just another of those problems of our dysfunctional health care system, one that will not go away until we institute a program of universal health care. It is a problem not faced by older people living in Canada or any other industrialized nation such as Japan, France, and Germany, all of which have universal health care systems. Neil Davis is a retired geophysicist and author of several fiction and nonfiction books. Much of the material for Dose of Reality is derived from his book, Mired in the Health Care Morass. Neil can be contacted at neildavs@mosquitonet.com. | ||
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