Should You Opt Out of Medicare? Pros and Cons

Leigh Page


November 13, 2018

In This Article

Avoid Medical Meddling by Bureaucrats

Also, Zetter says that Medicare enhances reimbursements if patients have more complications. He points to Medicare's extra chronic care management fee for patients who have multiple chronic conditions, which he says many doctors still don't take advantage of.

Huntoon, however, maintains that low payment is not the major reason most physicians opt out of Medicare. Instead, it is "government meddling in medical care" with rules and regulations, he says.

Pro: There Aren't Any Alternatives

One popular alternative to opting out is to stop accepting new Medicare patients. "It's a way to limit or trim your practice," La Penna says.

This is particularly popular among primary care physicians. A KFF survey found that 28% of primary care physicians were not taking new Medicare patients in 2015.[8]

However, Huntoon notes that not accepting new Medicare patients still means you're in the Medicare program. "You're still subject to Medicare rules and regulations, which is the chief reason for opting out," he says.

Another alternative to opting out is become a nonparticipating (nonpar) physician in Medicare. A 2016 study found that 4% of physicians are nonpar.[9] This group is much larger than the 0.7% of physicians who opt out, but the nonpar option is complicated and many physicians shy away from it, Zetter says.

Under this designation, doctors can decide on a case-by-case basis whether they want to bill Medicare as a participating or as a nonpar physician. As nonpar doctors, they agree to accept 95% of the usual Medicare reimbursement. But they make up for this loss—and make a little more money than participating doctors—by billing the patient an extra amount, or "balance bill," which is not allowed in regular Medicare.

Nonpar physicians can make up to 115% of the rate that participating physicians are paid. However, Huntoon reports that some states, including New York, impose a lower maximum rate than the Medicare's nonpar maximum. Another problem is that billing companies hired by practices sometimes forget to bill the nonpar rate when they have just one or two nonpar doctors, and this can get practices in trouble for overpayment, La Penna says.

The different reimbursement for nonpars annoys Medicare payers. "They see nonpar as a real pain," Cohen says. Add to this the fact that nonpar physicians are still affected by all of Medicare's draconian regulations.


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