Why Some Healthcare Providers Don't Accept Medicare or Other Insurance

Not all healthcare providers accept Medicare. Some do not even take private insurance anymore. Medicare and Medicaid have both seen significant changes in recent years and commercial insurance plans have increasingly decreased reimbursement rates. For these reasons and more, many healthcare providers have turned away from the bureaucracy in favor of a more simple approach.

Administrative Burdens

Medicine has become a bureaucracy. Healthcare providers have to fill out form after form to get insurance, Medicare included, to cover certain tests and treatments. They may need additional staff to handle the extra paperwork, phone calls, resubmissions, and negotiation with insurance companies. In a very convoluted process, insurers can deny coverage for patients who truly need it. This limits how a healthcare provider practices medicine.

Speaking of practicing medicine, Medicare wants to tell healthcare providers how to do just that. MACRA, MIPS, MU, PQRS, VBPM. The acronyms alone are enough to give any practitioner a headache. Without going into details about each one, these are different incentive programs that the Centers for Medicare and Medicaid Services (CMS) requires of its healthcare providers. Each program has its own set of stringent requirements and if they are not met, your provider could face penalties. It also affects how your healthcare provider enters information into your medical record.

This brings us to the electronic health record (EHR). While the intent was good (to streamline access to medical data), the implementation has been challenging to say the least. There is no standardized EHR system, so healthcare providers cannot share information with other medical providers involved in your care. The data entry itself can be onerous, regardless of which system you use. When you add all the CMS incentive programs to the mix, your practitioner is clicking away at boxes to "meet criteria" more than he is caring for patients. In fact, a 2017 study in Health Affairs shows that your healthcare provider now spends more time on the EHR than in face-to-face time with patients.

Financial Burdens

On average, Medicare pays healthcare providers only 80 percent of what private health insurance pays (80% of the "reasonable charge" for covered services). Even then, private plans tend to keep their rates on the low end. Many people argue that Medicare reimbursements have not kept pace with inflation, especially when it comes to the overhead costs of running a medical practice.

When it comes to getting paid, Medicare is fraught with delays. The same can be said for commercial plans. CMS reports that an electronic claim may be paid as early as 14 days and a paper claim as early as 28 days from the time it is received but the reality is often quite different. If there are any questions regarding the claim (and even if there are not), it could take months for a provider to be reimbursed.

Also, Medicare regularly cuts the rates of reimbursement, which means healthcare providers earn less for office visits and various procedures. In 2019, CMS plans to implement a new model that will pay flat-rates for office visits, regardless of how complicated they are. This will significantly reduce payments to healthcare providers who care for elderly patients with multiple chronic medical problems.

Healthcare Provider Burnout

When it comes to medicine, the health and wellbeing of people are at stake, not only for patients but for healthcare providers too. Being a practitioner is a vigorous job with long hours and life-changing responsibilities. It can take its toll, physically and emotionally, especially when the healthcare provider does not feel supported by a system that seems to be driven more by insurance profits than patient care. The truth is that healthcare providers have the highest suicide rate of any profession.

These days, healthcare providers face increasing demands with fewer resources. Low Medicare and insurance reimbursement rates can make it difficult for a healthcare provider to stay in private practice. If a practitioner does not own their own practice (fewer and fewer do these days), their employers often require them to see more patients. With only so many hours in the day, seeing more patients means spending less time with each of them. Each of those visits comes with its own administrative hoops and many healthcare providers have to work late or otherwise take their work home with them to finish up the necessary documentation. This makes it harder to maintain work-life balance.

Simply put, many healthcare providers are burned out. To take back control, some healthcare providers have chosen to opt out of Medicare and the big insurance companies to run practices that better appeal to their sensibilities. In this way, they can see fewer patients and spend more quality time with them.

Opting Out of Medicare

The majority of providers who care for adults do accept Medicare for insurance. It is a vital part of their medical practice. Some healthcare providers that opt-in for Medicare, however, choose not to participate in the Medicare Physician Fee Schedule. The Fee Schedule is released each year and is a recommended list of prices for medical services. A "participating provider" accepts assignment and cannot charge you more than this amount. A "non-participating provider" can charge you up to 15 percent more (known as a limiting charge) and still be part of the Medicare program.

Other healthcare providers and medical practitioners opt-out of Medicare altogether. They may choose to accept private insurance plans or may choose to have their patients pay out of pocket for all services. Some practices have even turned to new models of care like concierge medicine and direct primary care. In these cases, your provider will have you pay a monthly or annual fee for care.

What You Can Do

Obviously, you cannot strong-arm your healthcare provider to accept Medicare. While you could pay out of pocket for your care or ask for a discount, it makes more financial sense to find a pracitioner who does take Medicare. The Medicare website provides a list of enrolled healthcare providers. If you have a Medicare Advantage plan, the insurance company will provide you with a directory of participating healthcare providers in its network.

Just because a practitioner accepts Medicare does not mean they will take you on as a patient. Because of the financial reasons listed above, some medical practices only accept a certain number of Medicare patients. Call ahead to find out if their office is accepting new Medicare patients.

Other people may turn to urgent care centers, also referred to as a "walk-in clinics", "stand-alone clinics", or a "doc-in-a-box" to get care. There are more than 8,000 of these clinics in the United States, and the majority of these centers do take Medicare patients.

A Word From Verywell

Not every healthcare provider accepts Medicare. Some practitioners go so far as to refuse insurance altogether, even private plans. The administrative and financial burdens Medicare put on practitioners may help you to understand why that is the case. With that information in hand, you can move forward and find a healthcare provider that best suits your needs.