Medicare Coverage of Hospital Physicians
Medicare Part A or Part B covers the services of a doctor in any setting. If a hospital inpatient is cared for by a doctor who's an employee of the hospital, that doctor's services are covered by Medicare Part A as part of the overall hospital charges. If a doctor's services are billed separately from hospital inpatient charges, Medicare Part B covers the doctor's services regardless of where the patient receives the care.
Medicare Part B can cover care provided not only by a medical doctor (M.D.) but also by an osteopath doctor, a certified nurse practitioner, an oral surgeon who isn't an M.D., and other providers. In order for Medicare to cover care from any provider, that provider must be certified by and participate in Medicare.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for doctor services, contact the plan directly.
What original Medicare pays:
Medicare Part B pays 80 percent of the Medicare-approved amount for a doctor's services that are billed separately from inpatient hospital charges.
If Medicare Part A covers a hospital employee doctor's services, the amount Medicare Part A pays is subject to the deductible and coinsurance amounts that apply to the overall hospital charges.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper.
The care must be performed or delivered by a healthcare provider who participates in Medicare.
Which doctors accept Medicare assignment?
Not every doctor may accept Medicare assignment (a payment agreement). Doctors who have been approved to accept Medicare assignment can fall into any of the following categories:
- Participating doctors accept Medicare assignment, meaning that they accept the Medicare-approved amount as payment for their services. These doctors charge the Medicare program 80% and the beneficiary 20% of the cost of the benefit.
- Non-participating doctors can choose to either accept or not accept Medicare assignment. If the doctor does not accept Medicare assignment, you might have to pay a 15% additional charge above the cost of the service, known as a Medicare excess charge. You would then be responsible for up to 35% of the reduced Medicare-approved amount instead of 20%.
Doctors who have opted out of Medicare may charge you whatever they see fit for services and supplies; and you are responsible for the full cost of these benefits.