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Jaxon Scott
Jaxon Scott

Choosing a Majority Billing Doctor: A Guide for Health Care Consumers



What You Have to Believe About Majority Billing Doctors




If you are a Medicare beneficiary or a health care consumer, you may have heard about majority billing doctors. These are physicians who accept Medicare's fee schedule as payment-in-full for all Medicare covered services, without charging any extra fees or balance billing patients. Majority billing doctors are also known as participating providers or assignment-accepting providers in Medicare terminology.




What You Have to Believe About Majority Billing Doctors



But what does it mean to be a majority billing doctor? Why are they important for the health care system and for patients? How many physicians have opted out of Medicare and what are the implications? In this article, we will answer these questions and more, and help you understand what you have to believe about majority billing doctors.


Introduction




What are majority billing doctors?




Majority billing doctors are physicians who agree to accept Medicare's fee schedule amounts as payment-in-full for all Medicare covered services. This means that they have signed a participation agreement with Medicare, agreeing not to charge any extra fees or balance bill patients for the difference between their charges and Medicare's payment. Medicare beneficiaries seeing a majority billing doctor can only be liable for the cost sharing required by Medicare, such as deductibles, coinsurance, and copayments.


Majority billing doctors are different from non-participating providers, who can accept Medicare patients but can also charge up to 15% more than Medicare's fee schedule amounts. Non-participating providers can also choose whether to accept assignment on a case-by-case basis, meaning that they can decide whether to bill Medicare directly or require patients to pay upfront and submit claims for reimbursement. Non-participating providers who do not accept assignment can balance bill patients for the difference between their charges and Medicare's payment.


Majority billing doctors are also different from opt-out providers, who have formally opted out of the Medicare program and do not accept any Medicare payments. Opt-out providers can set their own charges and enter into private contracts with Medicare beneficiaries, who agree to pay the full amount out of pocket and not seek any reimbursement from Medicare.


Why are majority billing doctors important?




Majority billing doctors are important for several reasons. First, they help lower the costs of health care for patients and taxpayers. By accepting Medicare's fee schedule amounts as payment-in-full, majority billing doctors reduce the amount of out-of-pocket expenses that patients have to pay. They also reduce the amount of bad debt that providers have to write off due to unpaid bills. Moreover, they help contain Medicare's spending growth by accepting rates that are often lower than those paid by private insurers.


Second, majority billing doctors help improve the quality of care and patient satisfaction. By accepting assignment on all Medicare claims, majority billing doctors simplify the billing process and reduce the administrative hassle for patients. They also eliminate the potential for surprise bills or disputes over charges that can cause stress and confusion for patients. Furthermore, they signal their commitment to serving Medicare beneficiaries and providing high-value care that meets Medicare's standards.


Third, majority billing doctors help increase access and choice for patients. By agreeing to participate in the Medicare program, majority billing doctors make themselves available to millions of Medicare beneficiaries who need health care services. They also give patients more options to choose from when looking for a provider that meets their needs and preferences. Additionally, they support Medicare's efforts to expand access to care through alternative payment models, such as accountable care organizations and medical homes, that require participating providers to accept assignment.


How many physicians have opted out of Medicare?




According to a report by the Kaiser Family Foundation, based on data published by the Centers for Medicare & Medicaid Services (CMS) as of September 2020, only 1% of all non-pediatric physicians have formally opted out of the Medicare program in 2020. The share of opt-out physicians varies by specialty, with psychiatrists accounting for the largest share (42%) of all opt-out physicians and the highest opt-out rate (7.2%). In all states except for three (Alaska, Colorado, Wyoming), less than 2% of physicians in each state have opted out of Medicare.


The report also notes that the number of opt-out physicians may not reflect the actual availability of providers for Medicare beneficiaries, as some opt-out physicians may still see Medicare patients under certain circumstances, such as emergencies or charity care. Conversely, some participating or non-participating providers may limit the number of Medicare patients they see or not accept new Medicare patients at all, due to various factors such as practice capacity, payment rates, or administrative burden.


Benefits of majority billing doctors




Lower costs for patients and taxpayers




One of the main benefits of majority billing doctors is that they help lower the costs of health care for patients and taxpayers. By accepting Medicare's fee schedule amounts as payment-in-full, majority billing doctors reduce the amount of out-of-pocket expenses that patients have to pay. For example, a patient who sees a majority billing doctor for a 15-minute office visit would pay $16.94 in coinsurance (20% of Medicare's payment amount), while a patient who sees a non-participating provider who does not accept assignment would pay $28.60 in coinsurance (20% of the provider's charge) plus $4.29 in balance billing (15% of the difference between the provider's charge and Medicare's payment amount), for a total of $32.89.


Majority billing doctors also reduce the amount of bad debt that providers have to write off due to unpaid bills. According to a study by the American Hospital Association, hospitals alone provided $41.3 billion in uncompensated care in 2019, which includes both charity care and bad debt. By eliminating balance billing and simplifying the billing process, majority billing doctors can improve their collection rates and reduce their bad debt expenses.


Moreover, majority billing doctors help contain Medicare's spending growth by accepting rates that are often lower than those paid by private insurers. According to a study by the RAND Corporation, Medicare's payment rates for hospital services were 67% lower than those paid by private insurers in 2018, while Medicare's payment rates for physician services were 13% lower than those paid by private insurers in 2017. By accepting these lower rates, majority billing doctors help reduce the overall cost of health care and contribute to Medicare's solvency.


Higher quality of care and patient satisfaction




Another benefit of majority billing doctors is that they help improve the quality of care and patient satisfaction. By accepting assignment on all Medicare claims, majority billing doctors simplify the billing process and reduce the administrative hassle for patients. They also eliminate the potential for surprise bills or disputes over charges that can cause stress and confusion for patients. According to a survey by NORC at the University of Chicago, 57% of Americans have received a surprise medical bill that they thought was covered by their insurance or that was higher than expected, and 40% of them found it very or somewhat difficult to pay it off.


Majority billing doctors also signal their commitment to serving Medicare beneficiaries and providing high-value care that meets Medicare's standards. By participating in the Medicare program, majority billing doctors agree to follow Medicare's rules and regulations, such as submitting claims electronically, reporting quality measures, and complying with audits and reviews. They also agree to accept Medicare's payment adjustments based on performance, such as penalties for excessive readmissions or hospital-acquired conditions, or bonuses for achieving quality or efficiency goals.


Furthermore, majority billing doctors can enhance patient satisfaction by offering more transparency and predictability in their charges. Patients who see majority billing doctors know in advance how much they will have to pay for their services, based on Medicare's fee schedule amounts and cost sharing requirements. They can also compare prices across different providers using tools such as Medicare's Procedure Price Lookup or Physician Compare websites.


More access and choice for patients




Challenges of majority billing doctors




Potential loss of revenue for providers




One of the main challenges of majority billing doctors is that they may face a potential loss of revenue by accepting Medicare's fee schedule amounts as payment-in-full. As mentioned earlier, Medicare's payment rates are often lower than those paid by private insurers, which means that majority billing doctors may receive less income for the same services. This may affect their profitability and sustainability, especially if they have high overhead costs or serve a large proportion of Medicare patients.


Majority billing doctors may also lose revenue by not being able to charge extra fees or balance bill patients for out-of-network services. For example, a majority billing doctor who performs a surgery at an in-network hospital may not be able to charge more than Medicare's payment amount for the surgery, even if the anesthesiologist or the pathologist involved in the procedure are out-of-network and charge higher fees. The majority billing doctor would have to absorb the difference or negotiate with the other providers to lower their charges.


Moreover, majority billing doctors may lose revenue by participating in alternative payment models that require them to accept financial risk and accountability for the quality and cost of care they provide. For example, a majority billing doctor who joins an accountable care organization may receive a share of the savings generated by reducing Medicare's spending growth, but may also have to repay a share of the losses incurred by exceeding Medicare's spending target. The majority billing doctor would have to invest in care coordination, data analytics, and quality improvement initiatives to achieve better outcomes and lower costs.


Administrative burden and complexity




Another challenge of majority billing doctors is that they may face administrative burden and complexity by accepting assignment on all Medicare claims. By participating in the Medicare program, majority billing doctors have to comply with Medicare's rules and regulations, such as submitting claims electronically, reporting quality measures, and complying with audits and reviews. These requirements may entail additional paperwork, staff training, software updates, and documentation efforts that can consume time and resources.


Majority billing doctors may also face administrative burden and complexity by participating in alternative payment models that require them to accept financial risk and accountability for the quality and cost of care they provide. As mentioned earlier, majority billing doctors who join accountable care organizations or medical homes may have to invest in care coordination, data analytics, and quality improvement initiatives to achieve better outcomes and lower costs. These activities may require additional staff, infrastructure, and partnerships that can increase operational and managerial challenges.


Furthermore, majority billing doctors may face administrative burden and complexity by dealing with multiple payers and plans that have different rules and requirements. Although Medicare is a single payer for majority billing doctors, they may still have to interact with other payers and plans that cover their patients' supplemental or secondary insurance, such as Medigap, Medicaid, employer-sponsored insurance, or retiree benefits. These payers and plans may have different eligibility criteria, coverage policies, payment rates, prior authorization processes, claim submission procedures, and appeal mechanisms that can create confusion and inconsistency.


Resistance from some stakeholders




A third challenge of majority billing doctors is that they may face resistance from some stakeholders who oppose their participation in the Medicare program or alternative payment models. Some stakeholders may have vested interests in maintaining the status quo or protecting their market share or profit margins. These stakeholders may include other providers who compete with majority billing doctors for patients or referrals; insurers who negotiate with providers for lower rates or higher quality; or policymakers who influence health care legislation or regulation.


Some stakeholders may resist majority billing doctors by lobbying against policies that support or incentivize their participation in the Medicare program or alternative payment models. For example, some stakeholders may oppose proposals that would expand Medicare's coverage or eligibility; increase Medicare's payment rates or adjustments; or create new alternative payment models or pathways. These stakeholders may argue that such policies would increase Medicare's spending growth; reduce providers' autonomy or innovation; or undermine private insurers' role or competitiveness.


Some stakeholders may also resist majority billing doctors by challenging their practices or performance in legal or public arenas. For example, some stakeholders may file lawsuits against majority billing doctors for alleged fraud or abuse; report them to regulatory agencies for alleged violations or errors; or criticize them in media outlets for alleged low quality or high cost. These stakeholders may claim that majority billing doctors are overbilling or underdelivering; violating patients' rights or preferences; or compromising care quality or safety.


Conclusion




Summary of main points




In conclusion, majority billing doctors are physicians who accept Medicare's fee schedule amounts as payment-in-full for all Medicare covered services, without charging any extra fees or balance billing patients. Majority billing doctors are important for the health care system and for patients, as they help lower the costs of health care for patients and taxpayers; improve the quality of care and patient satisfaction; and increase access and choice for patients. However, majority billing doctors also face some challenges, such as potential loss of revenue for providers; administrative burden and complexity; and resistance from some stakeholders.


Call to action for readers




If you are a Medicare beneficiary or a health care consumer, you may want to consider choosing a majority billing doctor for your health care needs. Majority billing doctors can offer you more transparency and predictability in your charges; more simplicity and convenience in your billing process; and more value and satisfaction in your care experience. You can find a majority billing doctor near you by using Medicare's Physician Compare website or by asking your current provider if they are a majority billing doctor.


If you are a physician or a health care provider, you may want to consider becoming a majority billing doctor for your practice. Majority billing doctors can benefit from lower bad debt expenses; higher patient loyalty and retention; and more opportunities and incentives to participate in alternative payment models. You can become a majority billing doctor by signing a participation agreement with Medicare or by joining an accountable care organization or a medical home that requires participating providers to accept assignment.


FAQs




What is the difference between majority billing doctors and non-participating providers?




Majority billing doctors are physicians who accept Medicare's fee schedule amounts as payment-in-full for all Medicare covered services, without charging any extra fees or balance billing patients. Non-participating providers are physicians who can accept Medicare patients but can also charge up to 15% more than Medicare's fee schedule amounts. Non-participating providers can also choose whether to accept assignment on a case-by-case basis, meaning that they can decide whether to bill Medicare directly or require patients to pay upfront and submit claims for reimbursement.


What is the difference between majority billing doctors and opt-out providers?




Majority billing doctors are physicians who accept Medicare's fee schedule amounts as payment-in-full for all Medicare covered services, without charging any extra fees or balance billing patients. Opt-out providers are physicians who have formally opted out of the Medicare program and do not accept any Medicare payments. Opt-out providers can set their own charges and enter into private contracts with Medicare beneficiaries, who agree to pay the full amount out of pocket and not seek any reimbursement from Medicare.


How can I find out if my doctor is a majority billing doctor?




You can find out if your doctor is a majority billing doctor by using Medicare's Physician Compare website, which allows you to search for and compare doctors and other health care professionals who accept Medicare. You can also ask your doctor directly if they are a majority billing doctor or if they accept assignment on all Medicare claims.


How can I become a majority billing doctor?




You can become a majority billing doctor by signing a participation agreement with Medicare, which means that you agree to accept assignment on all Medicare claims for all your Medicare patients. You can also become a majority billing doctor by joining an accountable care organization or a medical home that requires participating providers to accept assignment.


What are the advantages and disadvantages of being a majority billing doctor?




The advantages of being a majority billing doctor include lower costs for patients and taxpayers; higher quality of care and patient satisfaction; and more access and choice for patients. The disadvantages of being a majority billing doctor include potential loss of revenue for providers; administrative burden and complexity; and resistance from some stakeholders. 71b2f0854b


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