Bills From Doctors Who Opted Out of Medicare: Private Contracts Explained

Some doctors and other providers "opt out" of Medicare, which means they don't work with the Medicare program at all. If you see one, you sign a private contract and pay the provider the full amount you agree to. Medicare.gov says Medicare won't pay for those services, your Medigap policy won't pay anything either, and the doctor isn't held to Medicare's payment limits, though the private contract doesn't apply to emergency or urgent care.

What does it mean when a doctor opts out?

Medicare.gov explains that doctors or other health care providers who don't want to work with the Medicare program may opt out. Providers opt out for at least 2 years. Every 2 years, the provider can choose to keep their opt-out status, accept Medicare-approved amounts on a case-by-case basis (non-participating), or accept assignment.

Opting out is different from not accepting assignment. A non-participating doctor still works with Medicare and is limited in what they can charge for most covered services. An opt-out doctor isn't.

What is a private contract?

If you choose to get care from an opt-out provider, Medicare.gov says you may need to pay upfront, or set up a payment plan with the provider through a private contract. Medicare.gov lists what happens if you sign a private contract:

• You and your provider set up your payment terms through the contract.
• You'll have to pay the provider the full amount for the services you get.
• Medicare won't pay for these services.
• Your Medigap policy, if you have one, won't pay anything for them.
• The contract doesn't apply to emergency or urgent care.

Why did I get a bill for the full amount?

If you signed a private contract with an opt-out provider, the full bill is expected. Check:

• Did you sign a contract? Ask for a copy.
• Was it emergency or urgent care? Medicare.gov says the private contract doesn't apply in those cases.
• Does the amount match the contract? The bill should follow the terms you agreed to.

If you didn't sign a contract and didn't know the provider had opted out, call the office and ask how they handled it.

How do I find out if my doctor opted out?

• Ask the office directly: "Have you opted out of Medicare?"
• Use Medicare.gov's lookup. Medicare.gov links to a list where you can find providers that opted out of Medicare.

Ask before your first visit, especially with a new specialist, therapist, or mental health provider.

Should I sign a private contract?

That's your decision. Some people choose to see an opt-out doctor they trust and pay out of pocket. Before you sign:

• Ask what each visit or service will cost. Get it in writing.
• Remember Medigap won't pay. Plan for the full cost.
• Ask whether tests or prescriptions will work with Medicare. Ask the doctor's office, and the lab or pharmacy, whether Medicare will cover tests or prescriptions this doctor orders. Check before you get them.
• Talk to your State Health Insurance Assistance Program (SHIP) first. Medicare.gov suggests contacting your State Health Insurance Assistance Program for help before signing a private contract.

Can I still use Medicare for other doctors?

Yes. The private contract only covers services from that one provider. You can keep using Medicare for all your other care.

What if I'm in a Medicare Advantage plan?

Medicare Advantage plans generally use their own networks. An opt-out provider usually won't be in a plan's network. Check with your plan before you get care.

How do I check an opt-out provider's bill?

1. Compare it to the contract. Make sure the service and price match.
2. Make sure it wasn't sent to Medicare. It shouldn't appear on your Medicare Summary Notice.
3. Look for emergency or urgent care. If the visit was urgent, the contract shouldn't apply.
4. Keep records for tax purposes. Medical expenses you pay yourself may count toward the Internal Revenue Service (IRS) medical expense deduction if you itemize.

What should I say when I call?

"I see a bill from Dr. [name]. Did I sign a private contract with your office? Can you send me a copy? This visit on [date] was for [urgent care / a routine visit]. Can you confirm the charge matches the contract?"

Frequently asked questions

What does it mean if a doctor opted out of Medicare?

The doctor doesn't work with the Medicare program. You'd sign a private contract and pay the full amount yourself.

Will Medigap pay for an opt-out doctor?

No. Medicare.gov says your Medigap policy won't pay anything for services under a private contract.

How long do doctors opt out of Medicare?

For a minimum of 2 years. Every 2 years, they can choose to stay opted out or work with Medicare again.

Does a private contract apply to emergency care?

No. Medicare.gov says it doesn't apply to emergency or urgent care.

Not sure whether a bill should have gone to Medicare?

Bill Review Coach is a monthly medical bill review service for seniors and their families. Snap a photo of the bill and your Medicare notice, and we'll tell you whether it looks like a private contract bill, a Medicare bill, or a mistake, and what to say when you call. You make the calls and write the emails; we help you know what to say.