Medicare Providers

Medicare providers are physicians and other healthcare practitioners who have been approved to offer their services to patients who are enrolled in a Medicare insurance plan. This means that they have agreed to receive the fee that Medicare is willing to reimburse them. Medicare dictates how much they are willing to pay the providers for their services.

Significance

• When an individual on Medicare seeks the service of a Medicare provider, he may or may not be responsible to make a co-pay. The provider must submit the patient's claim (bill) to Medicare directly in order to receive payment. For example, a psychiatrist may charge $200 for a consultation. However, if she has chosen to become a Medicare provider, she will receive the amount of money that Medicare deems appropriate for her service; this can be significantly lower, such as only $75.

Function

• Being a Medicare provider and accepting the Medicare-approved fee (as opposed to their own) is not meant to indicate the participants' quality and effectiveness in their field. Since the cost of health care is at an all-time high, most people can't afford to pay for their medical expenses out-of-pocket. By becoming a Medicare provider, the practitioners make themselves available to many more patients and don't have to deal with issues of unpaid bills and delayed payments; Medicare providers will only have to deal with Medicare.

Features

• Providers are issued a provider number. They use this number to submit the claims of their patients after they've performed a service. Medicare providers are not limited to physicians; they include social workers, physical therapists, nurse practitioners and physician assistants. Facilities like hospitals, rehabilitation centers, pharmacies and blood labs are also (for the most part) included in the Medicare provider category. A lab may charge hundreds of dollars for a simple blood count workup, but if the patient has Medicare and the lab is part of that network, it must accept the Medicare approved cost as opposed to general fee.

Identification

• Medicare's website provides information about the healthcare providers that are part of their plan. Their provider profiles include things like their area of specialty, educational background and training, the languages they speak and other affiliations (hospitals) that they are a part of. Also listed are the providers' addresses and contact information. Individuals who have Medicare can go online to locate a specialist in their area and check the status of any of the claims that they've submitted. Medicare providers can also access their information and update their listing (see Resources below).

Considerations

• It's important to be aware of the fact that not all physicians listed on the Medicare site are only the participating ones. A participating provider usually has the letter "P" by their name, which means they've agreed to the assignment on all claims. If a physician is "Non-Participating," it means that she can select her claims on an individual basis and has the option to reject an assignment. When that happens, Medicare pays the individual directly as opposed to the doctor. The doctor may also bill the individual for an additional amount of money.