Selecting Health-Care Providers
In This Chapter
- The differences among health-care providers
- Choosing a health-care provider who works with Medicare
- How Medicare sets physician fees
- The impending physician shortage and how it is being addressed
Knowing what services Medicare provides and how to enroll in the program are key concepts for you to understand. It may be even more important to recognize who should be providing that care and where it can be performed. You will cross paths with many different types of health-care providers in your lifetime—doctors, nurse practitioners, physician assistants, midwives, and more. How you select your medical providers will make a difference for your health-care experience.
What Providers Count
Everyone should have a primary care provider (PCP) to coordinate and provide preventive medicine. For years, the phrase PCP had been synonymous with primary care “physician,” but due to the increasing numbers of other trained professionals practicing in primary care fields, the phrase was generalized to primary care “provider.” You may consider a nonphysician provider as your PCP if they provide the bulk of your care, but does Medicare agree?
The road to becoming a physician may be different for each person. All physicians practicing in the United States have completed medical school, whether in the United States or abroad. For those taught in the United States, there are two different training paths, allopathic and osteopathic.
Allopathic medical schools are the traditional medical schools you have come to learn about in the television and movies. There are 136 allopathic medical schools across the country accredited by the American Medical Association. Education occurs over four years with didactic training in the basic medical sciences and clinical rotations for hands-on experience. A graduate from an allopathic medical school becomes a medical doctor (MD).
Osteopathic schools provide the full scope of medical training that allopathic medical schools do but also include osteopathic manipulative medicine (OMM) as a key tenet. OMM focuses on hands-on techniques to manipulate your muscles and joints as an approach to diagnosis and treatment. There are 26 osteopathic medical schools accredited by the American Osteopathic Association. A graduate from osteopathic medical schools is referred to as a DO, a doctor of osteopathy. Despite their training in medical school, only a fraction of DOs practice OMM in clinical practice.
DID YOU KNOW?
Medicare provides a portion of the funding for residency training via direct medical graduate payments (DMGP) to teaching hospitals. Medicaid, the Department of Veterans Affairs, and the Department of Defense are other federal sources of funding for residency training. The funds are used towards resident salaries, faculty salaries, and institutional overhead costs. Limits on the number of residents Medicare will approve for DMGP payments were set in 1997 by the Balanced Budget Act and has not been increased since that time.
After medical school, future practicing doctors must enter a residency in the medical field of their choice. These programs vary in length depending on the specialty but are at a minimum three years in duration. Some of the residency slots may be slated specifically for allopathic graduates or osteopathic graduates. Graduates of foreign medical schools may also apply for residency programs. In order to practice clinical medicine in the United States, training in an American residency program is required.
Through residency training, the doctor in training must pass a series of examinations known as the United States Medical Licensing Examination (USMLE), of which there are three parts. This testing allows each physician to demonstrate their clinical knowledge and application of key principles. Physicians can then apply for licensure in their state(s) of choice. At this point they are legally clear to practice medicine.
Beyond medical licensure, many physicians will then certify in their specialty with yet another examination. Some private insurers, including Medicare, will only allow coverage for services provided by board-certified physicians. Those physicians who are board-eligible may have limited insurance options that will accept them for coverage.
DEFINITION
Board-eligible and board-certified are not the same thing. A board-eligible physician is one who has completed a residency program but has not yet taken, or perhaps has even failed, the certification examination in his specialty. The term board-eligible can be used up to seven years after residency. Board-certified means the physician has met the certification requirements, including passing of an examination, in their specialty.
Taken together, your Medicare doctor will have completed 11 years of training—four years of undergraduate training, four years of medical school, and at least three years of training in residency with four in-depth examinations—plus Drug Enforcement Administration (DEA) licensure for prescription of medications.
Nurse Practitioners
Nurse practitioners (NPs) go through a lengthy training process as well, and have done so since 1965. Training requires completion of a four-year bachelor’s degree in nursing followed by a two- to four-year program in which they specialize as a nurse practitioner. The latter program generally results in a master’s degree, but some may earn a doctoral degree, specifically a Doctor of Nursing Practice. There are 350 NP training programs available at colleges and universities across the country accredited by the American Association of Nurse Practitioners (AANP). Similar to medical school trainees, NP students undergo an extensive series of lectures and clinical rotations during their training. Training beyond high school averages six to eight years.
An NP must then complete an examination for national licensure known as the National Council Licensure Examination (NCLEX-RN) and also apply for licensure in the state where they will practice. After all these steps are taken, Medicare then requires that an NP be certified in their field before they will accept him for coverage. The AANP and the American Nurses Credentialing Center (ANCC) are two organizations that offer approved certification.
The scope of practice of an NP is generally similar to that of a physician, diagnosing and treating conditions. Certain areas of expertise may be limited depending on differences in training. The majority of states require physician supervision of an NP though the doctor may not necessarily have to be physically present to meet guidelines in certain states; being accessible by telephone or online also qualifies. If you live in one of the following 17 states or the District of Columbia, an NP can practice with full authority without requiring physician supervision.
- Alaska
- Arizona
- Colorado
- Hawaii
- Idaho
- Iowa
- Maine
- Montana
- Nevada
- New Hampshire
- New Mexico
- North Dakota
- Oregon
- Rhode Island
- Vermont
- Washington
- Wyoming
As a Medicare beneficiary, you can select an NP as your PCP if you are in hospice, but a doctor must be the one who diagnoses you as having a terminal illness. In this case, a physician-NP team is essential.
Similar to doctors, an NP will require a DEA number if they intend to prescribe medications; additional licenses for drug dispensing may or may not be needed depending on the state. Many states allow NPs to prescribe medications, some with limitations on controlled medications (Alabama, Arkansas, Florida, Georgia, Louisiana, Missouri, Oklahoma, South Carolina, Texas, and West Virginia), and some outright not allowing for prescription management (Florida). As to U.S. territories, Puerto Rico does not allow an NP to write prescriptions and there are marked restrictions on what an NP can write in the U.S. Virgin Islands.
DID YOU KNOW?
There have been decades of debate about whether nonphysician providers should be considered qualified to be primary care providers (PCP). Physician organizations such as the American Medical Association have argued that nonphysician providers do not have adequate training to offer this level of care. Multiple states have acknowledged the expertise and quality care given by these nonphysician providers by allowing them to practice without restriction.
Medicare pays NPs differently than doctors but you, as a beneficiary, will be charged the same. The program usually pays them only 85 percent of the usual physician fee unless they meet the “incident-to” provision. This specifically states the NP is working under direct supervision of a physician who is on the premises or the NP is providing follow-up care to a condition first diagnosed and treated by a physician. If “incident-to” criteria are met, an NP may be reimbursed for the full cost of the care provided.
Physician Assistants
The first physician assistants (PAs) graduated from Duke University in 1967. As of 2012, there were 86,700 PAs in the United States and the number is rising, with 181 accredited training programs under the Accreditation Review Commission on Education for the Physician Assistant.
There are different routes a PA could take to complete training. If training is started immediately after high school, one could opt for an accelerated PA program which would take five years to complete. Otherwise, one would complete a bachelor’s degree that satisfies certain prerequisites in the meantime, and then apply to a PA program which generally requires an additional two years to complete (for a grand total of six years).
To qualify as a provider under Medicare, a PA must be licensed in the state they practice as well as certified by the National Commission on Certification of Physician Assistants.
There are similarities and differences between NPs and PAs. With regard to medication management, state regulations limit controlled medication prescribing in Alabama, Arkansas, Arizona, Florida, Georgia, Hawaii, Louisiana, Maine, Missouri, Montana, Oklahoma, South Carolina, Texas, and West Virginia; and do not allow for any prescriptions in Florida or Kentucky. Puerto Rico and the U.S. Virgin Islands also disqualify PAs from prescribing these medications. Payments to a PA are reduced to 85 percent of what a physician would be paid but Medicare may pay 100 percent of the charges if “incident-to” provisions were met.
A PA never has the full authority of care that has been allowed for NPs in certain states. PAs must be part of a physician team and have an assigned physician documented as their supervisor. This physician must work in the same state and must be readily accessible to guide diagnostic and treatment care plans even if they are not present on the premises. A PA also cannot be assigned as a PCP to a Medicare beneficiary who is on hospice.
Picking the Right Provider for You
It would be wonderful if you could pick whatever health-care providers you liked and be assured that they would accept your insurance and give you the best in quality care. More and more providers are making choices about whether they will accept Medicare for payment. This could affect your bottom dollar. There are key aspects you have to understand about your provider that will help you to make an educated decision.
Your health-care provider has a choice to make—whether to opt-in or -out of Medicare. Those who opt-in are called accepting providers. If your provider does not accept Medicare for payment, you are out of luck. Even if the services he provides or orders, such as laboratory studies or X-rays, would otherwise be covered by Medicare, Medicare will not pay. A contractual agreement needs to be in place between the federal program and your provider for any payments to exchange hands. Medicare will also not reimburse you separately for services.
DEFINITION
An accepting provider has signed an agreement with Medicare to accept their policies in order to receive payment.
The exception would be if a nonaccepting provider referred you to another provider for care who did opt-in to accept Medicare. The referral visit would be covered.
Physicians who do not accept Medicare will often have you sign a contract agreeing to their terms and conditions, including that they do not accept Medicare for payment. You must know that it is against the law for them to put any limitations on emergency care in these contracts. It would be outright unethical for them to turn you away for care for any reason, including their nonaccepting status, if you walked into their office in a medical emergency.
It is in your financial interest to find a provider that accepts Medicare, if you need it, but sometimes that may not be possible. You could live in an underserved area with a limited selection of primary care providers or specialists that accept Medicare.
Numerous reasons exist why a provider may choose to not accept Medicare, though they may not seem all that reassuring from your perspective. To circumvent Medicare’s increased red tape and regulatory requirements, to avoid the high costs of routine board examinations and certifications, or to have increased control over what they can charge are just a few examples.
Participating Providers
Accepting Medicare for payment is only one piece of the puzzle. Your health-care providers must also decide if they will participate in Medicare as a participating provider. Though the terms accepting and participating sound similar, they mean different things.
DEFINITION
A participating provider is an accepting provider who also agrees to Medicare’s fee schedule. A nonparticipating provider, while also an accepting provider, agrees to accept only some of the fee schedule or none at all.
Participation does not relate to accepting Medicare for payment, but to agreeing to a plan that sets fixed fees for services. This is also referred to as “accepting assignment.” Assignment only applies to Original Medicare and not Medicare Advantage Plans.
This pre-set list of fees determines what a provider can charge you for services. This means your provider cannot then go behind Medicare’s back and ask you to pay the difference for what they think is their fair share. They can bill you the amount that Medicare recommends and not a penny more. This leaves you to pay only your deductible and coinsurance or copays as dictated by your Medicare plan. Working with health-care providers who accept assignment saves you from being overcharged and saves you money. The Medicare Physician Fee Schedule is set every year for all services that Medicare may contribute payment but is not as straightforward as you would think. Then again, how many federal programs are? The fee schedules are based on complicated calculations that require conversion factors that take into account where you receive those services. Still, it offers a way to standardize charges across a geographic area. It’s meant to be fair.
CAUTION
Medicare offers free preventive screening tests such as mammograms and colonoscopies but they will only be free if your provider accepts assignment.
You should ask your provider if they accept Medicare. However, do not ask if they participate in Medicare. Some offices may misunderstand that they are “participating” because they accept “some” of the fee schedule when they are technically nonparticipating for that very reason. It is an all or none deal. Don’t let the lingo confuse you.
Instead ask specifically if your health-care provider accepts assignment. If they do not accept assignment, ask them if it is for all services or certain services. It is up to you to make a decision about the odds of your needing those services or not. Ideally, you would prefer a provider who accepts assignment to save yourself the most money.
Limiting Fees
Providers who do not accept assignment still have to contend with Medicare. In order to receive payments, they still have to agree to some terms and these are defined by a limiting charge. This allows a nonparticipating provider to charge up to 15 percent more than the Medicare Fee Schedule. In this case, Medicare pays the same amount they would have otherwise paid (80 percent of the Medicare Fee Schedule price) and the extra charges go to you (20 percent coinsurance + 15 percent limiting charge). If you had not already spent the amount of your deductible during the year, the deductible would also be included toward your expense for the service.
Loraine had been travelling when she developed severe dizziness. With her primary care doctor a hundred miles away, she needed to seek care at a local clinic. There were two clinics to choose from; both accepted Medicare patients, the first accepted assignment but the second did not. Assuming Medicare set the cost of the visit at $100, Loraine would pay $20 at the first clinic (she pays a 20 percent coinsurance while Medicare pays 80 percent). At the second clinic, she would pay $35. This is because the second clinic added a 15 percent limiting charge to their fee, increasing the cost to $115. Since Medicare only recognizes their set cost for the visit, the first $100 in this case, she would be left to pay for the difference herself. Which would you choose?
Limiting charges do not apply to nonparticipating suppliers of medical equipment. They can charge you whatever they want, so check with the company about assignment before you make any purchases. You are more likely to get a better deal if you use a participating supplier that has accepted assignment.
It would seem that a nonparticipating provider gets a better deal than a participating one, making up to 15 percent more for every service. In the end, however, their patients suffer by losing access to what would have otherwise been free preventive screening services under the Affordable Care Act. These tests would still be available to these beneficiaries, but they would be obligated to pay a coinsurance, typically 20 percent of the cost. This provides an incentive for primary care physicians to accept assignment, and indeed the majority do.
Getting a Second (or Third) Opinion
There are times when you may feel like you need an extra set of eyes on your health situation. A recommendation for nonemergency surgery is one of those times. Sometimes a second opinion will help you to make an educated decision about how to proceed.
CAUTION
If your doctor believes you need emergency surgery, there is no time to wait. Holding out for a second opinion could risk your health and even your life.
Medicare will only pay toward a second or even a third opinion only if the surgery is recommended for a medically necessary reason. Cosmetic surgery, for example, is off the table.
Generally speaking, you should seek your second opinion from a medical office separate from the one where you had your initial evaluation. Surgeons from the same group may review your case together and this may not offer you an objective second opinion. To save money, you should also have all tests and study results forwarded to the new provider for review. Medicare may not cover the cost of a repeat test in such a short period of time unless it was reasonably expected to have changed since the first one was completed, again a determination of medical necessity.
Of course, you should select a second opinion from a health-care provider who opts-in for Medicare and hopefully accepts assignment. Know that requesting a second opinion does not obligate you to change providers for the long haul. You can always return to the original provider for care if you choose.
Are There Enough Doctors?
It may be harder to find a doctor as time marches on. A physician shortage is expected by 2020 due to multiple factors:
- Of the 830,000 physicians in the United States, nearly half of them are in their 50s. Based on their age, one-third of doctors are expected to retire in the next decade.
- Passage of the Affordable Care Act has added more than 30 million people into the system that would not have previously had access to health care, increasing demands on providers.
- Baby boomers are reaching Medicare age at a rapid rate. With age comes more complicated medical issues and increased demand for services, both primary care and subspecialty.
- The number of residency training positions for physicians has not changed since 1997 because the federal government has not increased the necessary funding.
- According to The Journal of the American Medical Association, more internal residency graduates are going into specialties compared to primary care at a rate of 5:1.
The Association of American Medical Colleges (AAMC) projects that by 2020, there will be a shortage of 91,500 physicians—45,400 in primary care and 46,100 in subspecialties. By 2025, that shortage will escalate to 130,600, with primary care providers contributing to 65,800 (50.4 percent) of that deficiency.
To compensate, existing medical schools have started to take on more students and new medical schools are on the horizon. There has even been talk about decreasing the length of medical training to get doctors into the workforce sooner.
Without sufficient residency positions to complete their training, however, it will make little difference. These fresh-faced medical school graduates cannot train the rigorous hours of a residency for free, and this intensity of training is necessary to build experience and expertise in their respective fields. More residency positions are needed but there has yet to be action taken by the government.
With further cuts being made to how Medicare pays doctors and hospitals, fewer doctors may opt-in for Medicare. This could exacerbate the physician shortage for the elderly and those with disabilities.
The Least You Need to Know
- All health-care providers must be licensed and certified in their respective fields to be compliant with Medicare.
- Nonphysician providers are reimbursed at a lower rate than physicians unless they meet “incident-to” criteria, where a physician is involved in the care of the patient.
- Only physicians and nurse practitioners can be primary care providers for hospice patients.
- Choosing a provider who accepts assignment will decrease your costs and allow you access to free preventive services.
- Medicare contributes funds toward training of resident physicians, but the number of available residency positions has remained fixed since 1997.
- America is approaching a health-care crisis with an impending physician shortage.