Doctors like Medicare

Recent articles I have read and my own experience interviewing dozens of physicians and their staffs give a clear indication that as far as the claim and payment process goes physicians prefer Medicare over commercial insurance.

The reason is simple; Medicare asks few questions, does not employ pre-certification and follows a pay and pursue claim policy. In other words, they pay a claim and later may asks questions and that’s a big maybe. It’s also why administering claims costs less and, at least in part, why Medicare fraud is so prevalent and why it often takes years to uncover it.

Physicians see the pre-authorization process, the questioning of care and other processes employed by insurers as driven by the profit motive. That’s not accurate. Those processes all result from the growth of health care costs over the years and by the demands of employers and other plan sponsors to do something about it. In part to weed out spending money on unnecessary care; something that is well documented.

While from the physician’s point of view they are dealing with an insurer looking to save money, the fact is in many, likely most, cases that insurer is acting as an administrator for a self-funded employer plan. The insurance company has no risk based on the claims paid. It is paid a fixed fee per month per participant to manage the plan.

Medicare and certainly M4A will have to employ the techniques used by insurers, or greatly reduce allowed fees or simply use various forms of rationing to manage costs, especially if out-of-pocket costs are eliminated.


  1. Do not believe what they tell you, when it comes to anything that involves healthcare.
    My wife went to an Immediate Care Center, for a skin infection, the cream that the doctor prescribed worked great. What is great about living in a city with only 60,000 people is, we were in and out in about 20 minutes, on a Friday afternoon. When we got the bill for $165.80, the insurance paid $28.66 and our copay was $28 with an insurance adjustment of $109.14. When I retired from the USAF I was told that the health insurance would pay 75% and I would be responsible for the remaining 25%. I can do math, it was my best subject in school and every bill that I get, I end up paying 50% or more every time. Beware, almost nothing is true about healthcare costs.


    1. I am always amazed at what they bill and what they will accept, unless you do not have insurance then you pay the max amount.


  2. I think there is another important part of why doctors like Medicare over private insurance. Consistency over what is allowed. Over time, doctors have learned what is covered and what is not covered and how much they can bill and how much they will get paid.

    Both my specialist doctor’s offices take at least dozen medical insurance plans or the variations those of various plans. Some plans requires different information for the claim. Some require pre-authorizations, some require this test over that test or this one before that one. Then there are the things that are not covered. We all would like to think that our doctors are giving us the best standard of care in the least expensive way and know what our plans allow so they will order the right test and treatments.

    But each plan is different and I do not expect the doctor to know the details of my plan when I do not know the details of my plan. I have even called BC/BS and have gotten different answers before and it is funny when they read back the transcripts and go “I wonder why they told you that?” Yes there is fraud and pharmaceutical companies giving free samples to encourage the use of their drug or their test, but when a patient says they can’t afford the treatment, that does nobody any good and doctors will learn how to code the treatments correctly to get paid. I think that Medicare covers so many patients that it is just easier and worth their time to learn how to do that versus learning all the other plans and how they change every year.

    For the same reasons when I retired, I got the plan that was as closest to the plan when I was an active employee because over the years I have learned what will cost me more money with this plan. It is very hard to comparison shop your insurance but I’ll leave that for another blog.


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s