Originally published June 29, 2015, last updated June 29, 2015

When Your Doctor Won't Accept Your Medigap Insurance

Written by Brian Hickey, Vice President of Insuractive

Medicare is so confusing that sometimes the people behind the counter at your doctor’s office who deal with it all day long even get it wrong. Sure, people make mistakes. But Medicare MarketPlace knows you don’t want someone else’s mistake to cost you. So, how do you avoid such a hassle? Let’s look at one  recent, real-life scenario. Unfortunately, we’ve seen it with increasing frequency — doctors refusing Medicare Supplement, or Medigap, plans by mistake.

We’ll call our Medicare MarketPlace customer Ruth (not her real name.) She switched her Medicare Supplement — also called Medigap — health insurance policy from one carrier to another after Medicare MarketPlace found a plan that would save her money. Her licensed insurance agent at Medicare MarketPlace reassured her that she could go to the same doctors under the new plan. But when Ruth showed up at her dermatologist, the person handling her paperwork informed her that the doctor was no longer accepting the carrier she had just switched to. Instead of her Medicare Supplement plan covering her out-of-pocket portion of the bill, she would have to pay it herself.

What did Ruth do? She left and promptly called Medicare MarketPlace.

We knew that the information Ruth was told was incorrect, so we jumped to action. We called the dermatologist’s office manager and Ruth’s insurance carrier. We learned from the office manager that the dermatologist’s office was negotiating with this particular carrier on rates for individual major medical and group insurance but never came to an agreement. So now, they said, that particular carrier would be “out of network” for Ruth.

But with Medicare Supplement  there is no network.

We explained to the office manager that if the provider accepts Medicare assignment, they must see Ruth and honor her Medicare Supplement insurance. Medicare assignment means that your doctor, provider or supplier agrees to accept the Medicare-approved amount as full payment for covered services. While the dermatologist’s office has the right to refuse an insurance company’s major medical plans, it cannot refuse to accept Medicare Supplement patients if it accepts Medicare assignment. The dermatologist’s office employees assumed that Ruth was “out of network” because the office no longer had a contract for the individual major medical and group insurance patients. This was the mistake.

Ultimately, the provider understood the mistake and allowed the patient to make a return appointment. The provider also thanked us for going above and beyond — now that they understand the differences, they can see more people they’d previously turned away.

Further complicating whether doctors are out-of-network is the fact that another Medicare-related program does indeed have networks. Medicare Advantage is a private insurance that covers Parts A and B and often prescriptions. With Medicare Advantage, in most situations, you must use the plan’s network of doctors and hospitals to get the lowest co-payments.

With Medicare and Medicare Supplement however, you are free to see any doctor who accepts Medicare.

We spent approximately two days working with Ruth’s doctor’s office and her insurance company to resolve the situation. Whether you purchase a Medicare Advantage, Medigap or prescription drug plan through Medicare MarketPlace, you can rest assured that we are here to help you — and your doctor’s office — clear up any confusion.