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Navigating the Original Medicare Part B Provider Network

By Martine G. Brousse (not AI!)

"The Medical Bill Whisperer"

Patient Advocate, Certified Mediator

AdvimedPro


November 22, 2024


if you have Original Medicare, you have Part B and you have access to a very large network of medical providers, individuals and facilities. 

Let's explore what the three provider types are, why you should you and how to save $.

 

Note: this information only applies to Original Medicare members. Those who have Medicare Advantage, also called Part C, must follow other rules and must use providers from smaller, local and restricted networks.

 

A. Part B refresher


  • Part B covers services by a professional or rendered out patient in a hospital, but also the

supplies used to diagnose and treat a medical condition, and the services to prevent

or detect a potential medical condition before it gets too late. 

  • Part B will include mostly Doctors and professionals of any specialty, but also durable 

    medical equipment - for example, a wheelchair or crutches- also the drugs infused 

    or injected as part of an outpatient hospital stay, administered in an infusion center 

    or a doctor's office. 

  • Part B also covers for ambulance services, mental health treatments and more.

 

B. The 3 types of providers

 

1. "Participating"

  • This is by far a huge number of physicians in the United States. Why? Because a practitioner automatically enrolled in the Medicare network unless they specifically opt out.

  • About 98% of all medical providers in the country participate with Medicare and always accept what is called “assignment”. This means they accept what Medicare approve as a fair price for their service as “payment in full”. They receive a direct Medicare payment, which is 80% of that allowance, and to only bill you - or your Medicare secondary carrier if you have one - for the remaining 20% copay.


2. “Non-participating“ providers do accept Medicare, but only accept assignment on a case by case basis. For example, they may accept a Medicare approved amount for an office visit, but not for a subsequent surgery.


3. The smallest portion of Medicare providers is called “opt out”.

This means the provider has submitted an affidavit to Medicare, indicating they never

accept Medicare assignment. They can charge their patients whatever fee they want, as

long as certain criteria (notification to the patient, having legally opted out..) are met.

 

C. Your wallet

 

1. “Participating” providers are the very best option to save the most.

  • Medical providers submit a claim directly to Medicare before they can charge you anything. Medicare processes the charges by applying a specific contractual allowance to every service or item. The resulting Explanation Of Benefit will show an 80% payment to the provider and a 20% copay to the member – with possibly the deductible

    at the beginning of the year.

  • If you have a Medigap secondary insurance, it should cover that 20% and possibly the deductible.

 

2. if you use a “non-participating” provider, well, it's a question of “maybe”

  • If they agree to accept assignment for that service or item, it falls under “participating “. You will just be liable for the 20% or your secondary insurance will.

  • If they don't accept assignment, you can only be charged up to 15% more than the Medicare approved amount. Your copay rises to 35% of the Medicare allowance. This additional 15% is known as a “limiting charge”.

  • Some states will max that limiting charge to less than 15%. You can find out what are the regulations in your own state by consulting the State Health Insurance Assistance Program (“SHIP”). In addition to that information, the website can direct you to resources and other programs to help you save even more money.

  • Of note, if you need the services of a clinical social worker or physician assistant, they can only be “participating” or “opt out”, but never “non-participating”.

 

3. “Non participating” providers cost the most

  • The provider could still bill Medicare to get a payment but also determine how much your liability is.

  • Or you could submit an invoice to Medicare to try and get reimbursed.

  • But you are responsible for the entire cost of the services or items if you are asked to sign an ABN form.

  • That form indicates ahead of time:

    . what charges are not going to be covered because the provider is opted out.

    . the $ amount payable (by you) for each one of those services or items.

    . it requires you to sign to confirm your acceptance of the financial responsibility for the full cost, as well as your understanding that Medicare will likely not reimburse you.

    . Even if the provider or you were to bill Medicare, no payment would be issued.

  • Medicare allows an exception and might cover Emergency services

 

D. TIPS

 

1.     Find out ahead of time what status the provider has, especially if “non participating.” Will the services you are about to receive be billed to Medicare as “participating” or “non-participating”? The difference means an additional 15% of the Medicare allowance at your cost.

2.     Double check the paperwork

There are several types of ABN forms: for home health services, for professional services, for skilled nursing facility services and even outpatient hospital services. Do not sign unless you know what financial cost will be your responsibility, and that there is no other way to get a Medicare payment.

3.     Visit my favorite website: medicare.gov:

  • to locate a provider meeting your needs

  • to compare specialists in your area

  • to find out which one is participating or might have opted out.

  • to speak with a Medicare Navigator to assist you with coverage and benefits, cost estimates and providers’ status.


Questioning and verifying are the best ways to avoid unpleasant bills and added costs later.



pie divided in 3


Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.

 

www.advimedpro.com - info@advimedpro.com - (424) 999 4705 - F (424) 226 1330

@martine brousse 2024 @ the medical bill whisperer 2024™

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