The problem with Medicare billing
Because claims are processed by Medicare administrative contractors, it can take about a month for the approval or denial process and for doctors to receive reimbursement.
Prior authorizations, especially with Medicare Advantage plans, are also problematic. For example, one 2022 study found that 18% of payment denials were for services that met coverage and billing rules.
Worse, all of this jockeying for coverage takes time. The average health care provider spends 16.4 hours a week on paperwork and on securing prior authorizations to cover services, according to the American Medical Association.
“A good 40% of my time is exclusively Medicare red tape paperwork,” Rahul Gupta says. “There’s a reason I spend 2-3 hours a night catching up on that stuff.”
Not only does this lead to burnout, but it also means that most physicians must hire an administrator to help with the paperwork.
In comparison, industry averages put the denial rate for all Medicare and private insurance claims at 20%.
“Excessive authorization controls required by health insurers are persistently responsible for serious harm to physician practices and patients when necessary medical care is delayed, denied, or disrupted in an attempt to increase profits,” Dr. Laroche said.
“Our office spends nearly 2 days per week on prior authorizations, creating costly administrative burdens.”
For Adeeti Gupta, the frustrations with Medicare have continued to mount. “We’re just at a dead end,” she said. “Authorizations keep getting denied, and the back-end paperwork is only increasing for us.”
Will more doctors opt out of Medicare?
When doctors don’t accept Medicare, it hurts the patients using it, especially patients who have selected either a Medicare Advantage plan or who become eligible for Medicare at age 65 only to find that fewer doctors take the government-sponsored insurance than in the past.
As of 2020, only 1% of nonpediatric physicians had formally opted out, per the Centers for Medicare & Medicaid Services. Psychiatrists account for the largest share of opt-outs (7.2%).
“Unfortunately, most doctors outside of hospital-based practices will reach a point when they can’t deal with Medicare paperwork, so they’ll stop taking it,” Rahul Gupta says.
A coalition of 120 physicians’ groups, including the American Medical Association, disputes that Medicare is paying a fair reimbursement rate to physicians and calls for an overhaul in how they adjust physician pay.
“Nothing much changes no matter how much the AMA shouts,” Rahul Gupta said in an interview.
What can doctors do
Prescription prices are another example of the challenges posed by Medicare. When prescriptions are denied because of Medicare’s medigap (or donut hole) program, which puts a cap on medication coverage, which was $4,660 in 2023, Dr. Gupta says she turns to alternative ways to fill them.
“I’ve been telling patients to pay out of pocket and use GoodRx, or we get medications compounded,” she said. “That’s cheaper. For example, for HRT, GoodRx can bring down the cost 40% to 50%.”
The American Medical Association as well as 150 other medical advocacy groups continue to urge Congress to work with the physician community to address the systematic problems within Medicare, especially reimbursement.
Despite the daily challenges, Rahul Gupta says he remains committed to caring for his patients.
“I want to care for the elderly, especially because they already have very few physicians to take care of them, and fortunately, I have a good practice with other coverages,” he said. “I can’t give up.”
A version of this article first appeared on Medscape.com.