As the Congress continues to work on reforming Medicare payments for physician services, a new Kaiser Family Foundation brief examines key provisions in current law that help provide safeguards and financial protections for beneficiaries when they visit their doctor, and explains how potential changes could affect beneficiaries, providers, and the Medicare program. These provisions include:
- The participating provider program encourages physicians and other practitioners to charge no more than Medicare fees for services provided to their Medicare patients, helping to limit the amount beneficiaries are required to pay for a visit to their doctor. Today, 96% of physicians and practitioners who are registered with Medicare are “participating providers.”
- Limitations on balance billing cap the amount “non-participating providers” can bill their patients above and beyond Medicare’s standard fees for each service, again limiting beneficiaries’ exposure to high cost sharing for physician services. Such balance billing has shrunk substantially over the past few decades, decreasing the total cost to beneficiaries from $2.5 billion in 1983 to $40 million in 2011.
- Conditions on private contracting provide safeguards when physicians “opt out” of Medicare and privately contract with Medicare patients. The provisions are designed to make patients more aware of their financial obligations under these arrangements, and to protect beneficiaries and Medicare from fraud and abuse. Less than 1 percent of practicing physicians have “opted-out” of Medicare and see Medicare patients only through private contracts.
Read Paying a Visit to the Doctor: Financial Protections for Medicare Patients online.
The Kaiser Family Foundation, a leader in health policy analysis, health journalism and communication, is dedicated to filling the need for trusted, independent information on the major health issues facing our nation and its people. The Foundation is a non-profit private operating foundation, based in Menlo Park, California.