Looking for Recommendation for ME/CFIDS Docs Who Accept Medicare

[AngelM]

I am in search of a ME/CFS doctor who has not opted out of Medicare. My supplemental insurance will pay 100 percent of the cost of a doctor who is not Medicare approved. But since my supplemental insurance bills first through Medicare, and then picks up what Medicare does not pay, I will be fined heavily by Medicare for using a doctor who has opted out altogether.

I live in Oklahoma, USA, would prefer to not have to travel great distances, but am willing to do so, if necessary. But cannot afford to see a physician who only accepts private pay. Since I have already been diagnosed with ME/CFIDS by a CFS physician/researcher (since retired), I primarily need to find someone to work with me on treatment(s). My former doctor referred me to Dr. Lapp in NC and Dr. Bateman in Utah, but Lapp has opted out of Medicare and Bateman is no longer taking patients. It is difficult to believe that there are no CFS specialists, or physicians with a working knowledge of CFS, other than the few whose names keep popping up on this and other forums.

I don’t mind being on a waiting list, but a waiting list of two to three years is ridiculous. My former CFS physician suggested I try an internal medicine doctor with knowledge of CFS. Any recommendations?

 

[Shoshana]

That sounds like a good suggestion from your former CFS doctor, but of course, I do not know any doctors to recommend.

I didn't know that you would be financially penalized (by Medicare) for going to a doctor who has opted out of Medicare! I can see that the supplemental would bill them first, to see that the service is refused by Medicare.

That's a tough situation, you are in.
And it Seems to me, to be another one of those ripple effects of having any illness, and especially of having one like ours.! I hope you find someone who can be helpful for you!

 

[AngelM]

i didn't know that you would be financially penalized (by Medicare) for going to a doctor who has opted out of Medicare! I can see that the supplemental would bill them first, to see that the service is refused by Medicare!

The penalty was new to me. But the insurance person I spoke with at Hunter-Hopkins said it would be huge. Need to find out more. I have Aetna Medigap and they pay what Medicare doesn’t, (and they told me that would be true even if I saw a doctor who did not accept Medicare). But all charges have to be billed through Medicare, regardless. So, according to the insurance person, Medicare knows if you have seen a doctor who has opted out, as opposed to a one who is not currently accepting Medicate or has not yet been approved. Maybe somebody on the forum can explain the mystery of this “opt out” and penalty business.

 

[Shoshana]

It is actually good for many of us, to have this information,
so thanks for sharing it, Angel, even though I know your primary posting reason, is to find a good doctor for you!

I knew Medicare is billed first, but did not know about the penalty.
Medicare has been good for me to have. I was much worse off without it, and it has some beneficial aspects (does not require referrals, costs less than other medical coverages... ) but there is a drawback that you encountered. Every type of insurance does have drawbacks, and some that we don't know until we encounter them, at bad timings!

But back to the goal....I hope someone has a doctor suggestion for you!

 

[Pisgah]

@AngelM I would like to be supportive in your search but I'm somewhat confused (which is not unusual,lol). Have you talked with the Aetna Medicap people for a full explanation as to how this would work with your policy? Particularly, I don't understand the difference between 'not medicare approved' and 'opting out' of medicare...I think as far as the insurance company would be concerned these would be treated the same since in both cases the medical provider is not agreeing to accept medicare rates.

I am on Medicare with a supplemental policy as well and looked into going to Dr. Klimas at NOVA and they have 'opted out' of medicare or filing insurance of any manner. They have one pay but would then provide the insurance info for me to submit to Medicare,etc. My understanding is that medicare and my policy would then reimburse me the amounts they would have covered/paid according to Medicare rates for the specific services rendered. So yes, the difference between fee charged and amount covered at Medicare rates could add up to a significant sum of money and I keep mulling this decision over.

It sounds like you are saying that your Medigap insurance might pick up what is not covered??? Who knows, there may be some divine policies still out there that will do this, especially if it is a "specialist that is needed who is not a medicare provider"....

 

[Pisgah]

@AngelM One possible Doctor that I believe takes Medicare and has a special interest in ME is
Dr. William "Skip" Pridgen. He is in Tuscaloosa, Al. I know of him only because of Cort Johnson on Health Rising site. If interested you can go to the site and search Tuscaloosa and it will bring the info up. Best wishes to you in finding a good Doc. Please let us know how all this turns out for you as there are many of us in a similar situation.

 

[Shoshana]

They have one pay but would then provide the insurance info for me to submit to Medicare,etc. My understanding is that medicare and my policy would then reimburse me the amounts they would have covered/paid according to Medicare rates for the specific services rendered. So yes, the difference between fee charged and amount covered at Medicare rates could add up to a significant sum of money and I keep mulling this decision over.

I did do this with doctors in the past, and it worked well for me. They did not bill Medicare for me, but I could use a short simple form, and send it to Medicare myself, I think the doctor office was willing to fill in just the few parts they needed to, and I filled in the rest (very short and simple it was ) and I mailed it to Medicare, and I did receive timely, prompt reimbursements, at that time.
I did not have any other insurance. For me, it was a big help in paying for the specialist who did not bill Medicare.

That is interesting that Pisgah noted, perhaps it is the difference in what the individual doctor charges, and Medicare's rate they pay for a specific service, that makes the financial difference.

 

[Shoshana]

That might be called, that the doctor "does not accept Medicare assignment"
which means that the doctor does not lower their rate to what Medicare deems the service should cost.
And the doctor does not deal directly with Medicare.

Doctors who "accept Medicare assignment" (I ask before I see them)
they accept the lower rate for the services, and they bill Medicare, receive payment, then the doctor office adjusts their fee lower, and leaves the 20 % balance co-pay, for either a person's supplemental insurance to pay, OR for a person with NO companion insurance to pay out-of-p-ocket, unless they(the doctor office) have some other program to lower costs for those in need.

However, the results of a doctor "opting out" might be different, I do not know.
Perhaps that means that they provide NO info to Medicare, to even verify that they have seen you, o r what service they provided, for what reason.

 

[Sushi]

. So, according to the insurance person, Medicare knows if you have seen a doctor who has opted out, as opposed to a one who is not currently accepting Medicate or has not yet been approved. Maybe somebody on the forum can explain the mystery of this “opt out” and penalty business.

This is not true in my experience. I have Medicare and a supplemental, and was the patient of an ME/CFS doctor who had opted out--I paid privately and directly to the doctor. Medicare was never involved and they would have had no way of knowing that I had seen this doctor. Certainly there was no penalty.

One possible Doctor that I believe takes Medicare and has a special interest in ME is Dr. William "Skip" Pridgen. He is in Tuscaloosa, Al.

As far as I know, Dr. Pridgen would only give one treatment--a combination of a prescription NSAID like Celebrex and an antiviral such as Valtrex. He has done trials with this combo for fibro patients and ME/CFS patients but I don't think he would look at the whole spectrum of ME/CFS symptoms as this combo treatment is based on his hypothesis that the root of these illnesses is herpes simplex.

 

[AngelM]

“So, according to the insurance person, Medicare knows if you have seen a doctor who has opted out, as opposed to a one who is not currently accepting Medicate or has not yet been approved. Maybe somebody on the forum can explain the mystery of this “opt out” and penalty business.”

The person I spoke with in billing said I would have to sign a document declaring that I would not send my private pay bill to Medicare. Very mysterious!!!!???

 

[Sushi]

The person I spoke with in billing said I would have to sign a document declaring that I would not send my private pay bill to Medicare. Very mysterious!!!!???

Some doctors require that; some don’t—not sure why.

Tip: to quote someone simply select the section that you want to quote with your mouse and you will see a pop-up that says reply or multi quote. Choose reply if you just want to quote once and shoes multiquote if you want to quote more than once.

 

[Stretched]

FWIW, I did a macro survey of primary care doctors in the Atlanta area who took Medicare and the results were only 3 of some 240 subscribed! That should be a crime! Our taxes supplement these rascals along the education path. Plus, Medicare is required in place of regular insurance after age 65, in U.S.

When doctors get successful they don’t want to accept Medicare’s negotiatiated payments and ‘opt out.’ Congress should get a good look at this and close the ‘opting out.’ BTW, the 3 who took Medicare looked third rate - foreign schools, etc.

 

[AngelM]

Some doctors require that; some don’t—not sure why.

Tip: to quote someone simply select the section that you want to quote with your mouse and you will see a pop-up that says reply or multi quote. Choose reply if you just want to quote once and shoes multiquote if you want to quote more than once.

Thanks, been wondering what I was doing wrong.

 

[Shoshana]

I have Medicare and a supplemental, and was the patient of an ME/CFS doctor who had opted out--I paid privately and directly to the doctor. Medicare was never involved and they would have had no way of knowing that I had seen this doctor. Certainly there was no penalty.

Just wondering about this issue with the insurances, for our general info.
If you paid the total privately, Sushi, or did your supplemental pay anything on it, perhaps results would differ.

Because my thinking has been that any supplemental or companion type of plan, would likely require a refusal of payment from Medicare before they would pay. They don't want to pay for anything that Medicare might pay on, first.
Therefore, I think, that
IF someone wants to use their supplemental, THEN they might have to have Medicare billed first.
If we pay the entire bill, ALL out-of-pocket, then I agree that Medicare would not need to be involved and would not know anything.

I am definitely not saying anyone is wrong, I am more wondering how this works, and adding in my knowledge of that process.
Maybe you would know, Sushi, because if your supplemental paid toward it, and did not require Medicare be billed first, then my knowledge is outdated.

 

[Shoshana]

The person I spoke with in billing said I would have to sign a document declaring that I would not send my private pay bill to Medicare. Very mysterious!!!!???

Now this is truly guessing, on my part, but this 'mysterious behavior'
might be because ,
some medical practices perhaps do not want ANYOne, especially any governmental agency, aware of what they are using for treatments or meds, etc, because they fear being held responsible (possibly even legally liable) for doing something considered "not proven" or "not medically appropriate" or "not ethical" or "misleading the patient with false claims, or to false hopes" or too far "off- lable" meaning that the med or treatment plan might have only been proven or approved or medically recommended for other ailments, and not for those that are present in that patient.

There could, instead, be some other entire reason why the doctor wants to be "invisible" to Medicare. I don't know.

 

[Sushi]

If you paid the total privately, Sushi, or did your supplemental pay anything on it, perhaps results would differ.

Because my thinking has been that any supplemental or companion type of plan, would likely require a refusal of payment from Medicare before they would pay. They don't want to pay for anything that Medicare might pay on, first.

My supplemental will only pay if Medicare pays first. If Medicare won't pay, then my supplemental won't pay either. But in this case I couldn't submit it to Medicare because I had to sign a paper with the doctor saying that I wouldn't. Not sure why they do that.

 

[AngelM]

FWIW, I did a macro survey of primary care doctors in the Atlanta area who took Medicare and the results were 3 of some 240 subscribed! That should be a crime!.

I agree. And it makes me question the motives of those physicians who do opt out. The disabled and those over 65 have no other options but Medicare unless they are willing to pay for a pricey policy plus what is taken out each month for Medicare Part A and B. Medicare Advantage plans are horrible, at least, from my experience. I understand many CFS doctors have left the university setting to set up practice independently. Now I understand why. I hate to think greed was their motive. Because they left a bunch of people in the lurch.

I would think a physician who chose to see patients AND do research would have to take Medicare, if their research grants were government funded. If that is not the case, then that federal loophole needs to be closed.

 

[Sushi]

I understand many CFS doctors have left the university setting to set up practice independently. Now I understand why. I hate to think greed was their motive. Because they left a bunch of people in the lurch.

I have found a good choice of doctors locally who take medicare in the major specialty areas--but ME/CFS specialists generally don't because they can't afford to. They need to spend at least an hour with a patient and Medicare will only reimburse them for about 20 minutes.

 

[valentinelynx]

I have found a good choice of doctors locally who take medicare in the major specialty areas--but ME/CFS specialists generally don't because they can't afford to. They need to spend at least an hour with a patient and Medicare will only reimburse them for about 20 minutes.

Exactly. It's not greed; it's frustration. Medicare reimbursement rates have fallen considerably in recent years, so, as @Sushi says, in order to keep the practice afloat, a Medicare doctor has to keep appointment lengths to about 15 minutes. This will not serve an ME/CFS patient.

There are many other problems with the Medicare program. Not only are reimbursements often lower than the cost of practice, but the payments themselves are delayed by months, if they come at all. Then there are agencies whose job is to analyze every charge to every patient, seeking errors: they are rewarded for finding "overcharges"–so they tend to find them, even if they aren't really overcharges. The government also annoys physicians with "practice improvement programs" in which a doctor's pay is docked if, for example, they don't use a Electronic Health Record (the reason why your doctor can't look you in the face during your appointment anymore—they must get the info into the chart, and if they don't do it in your 15 minute appointment, they have to spend hours after work inputting the data). And, there are a zillion other little "metrics" a Medicare doctor must meet to get full payment.

Another nasty aspect of Medicare is that it prohibits doctors from giving patients a break. If your doctor knows you can't pay for a service and wants to waive your fee, he or she would now be considered to commit Medicare fraud if they do not offer the same deal to every Medicare patient! And, Medicare can change their rules and make them apply retroactively.

So, in accepting Medicare, physicians commit themselves to spending too little time with sick patients, wasting time with silly government requirements, paying a billing department just to keep up with the arcane rules of how to bill Medicare and actually get paid, and, always living under the fear of innocently doing something wrong and being prosecuted for Medicare fraud. After all, the government actively encourages patients to accuse doctors of Medicare fraud, and some patients are easily disgruntled.

For us ME/CFS patients, it means that doctors that are committed to caring for us cannot afford to accept Medicare. A visit for an ME/CFS patient probably should take at least a couple of hours, and there are only so many hours in the day. Meaning the price of the visit has to be steep. It's not just the doctor that's being paid: it's the rent on the clinic, the pay of nurses and MAs and receptionists, and any medical supplies. There are ways to make a lot of money in medicine, but it's not by treating ME/CFS patients!

 

[Pisgah]

This is not true in my experience. I have Medicare and a supplemental, and was the patient of an ME/CFS doctor who had opted out--I paid privately and directly to the doctor. Medicare was never involved and they would have had no way of knowing that I had seen this doctor. Certainly there was no penalty.

As far as I know, Dr. Pridgen would only give one treatment--a combination of a prescription NSAID like Celebrex and an antiviral such as Valtrex. He has done trials with this combo for fibro patients and ME/CFS patients but I don't think he would look at the whole spectrum of ME/CFS symptoms as this combo treatment is based on his hypothesis that the root of these illnesses is herpes simplex.

Thank you @Sushi for providing this additional info and thus avoiding a possible wild goose chase!