Why Doctor Opted Out of Medicare
By Robert G. Schwartz, M.D.
June 12, 1998
Part and parcel of a physician's soul is caring
for the sick. It's what motivates one to enter the
medical profession. Yet, most citizens who have
Medicare coverage today are finding fewer physicians
who will accept new Medicare patients. In fact,
some physicians, including myself, are dropping
out of the Medicare program altogether.
Why would a physician who has treated Medicare
patients for over 15 years suddenly decide to opt
out of the Medicare program?
The federal government, while possibly well intentioned,
has now created such a complex maze of Medicare
rules and regulations that compliance is practically
impossible. By the time the physician figures them
out, they have changed. By the time one realizes
that they are not in compliance, they are audited.
At this point, the federal government is not concerned
that the doctor was not aware of the dynamic rules
and regulations. To them, the doctor is committing
fraud and will be fined up to $10,000 per fine item
To add to the frustration of keeping abreast of
ever-changing rules and regulations, when a physician
has a problem with Medicare, he does not know where
to turn for help. Medicare is run by the Health
Care Financing Administration (HCFA). They have
regional offices all over the United States. For
example, South Carolina's regional HCFA office is
Since the Medicare program is so large, HCFA contracts
with other companies to actually run the program.
HCFA calls these companies the Intermediaries. In
South Carolina, the Medicare Intermediary is a subsidiary
of Blue Cross Blue Shield, called Palmetto Government
Even the intermediary admits that is has a hard
time keeping abreast with all of HCFA's rules and
regulations. They may make rulings against what
would otherwise seem to be obvious HCFA policy.
If pointed out to them, don't be surprised if they
are deaf to the complaint.
If a physician provides care that he or she believes
to be medically necessary and Medicare pays for
it, but then later decides during an audit that
it was unnecessary, the physician will be penalized.
The most common and on-going disagreement between
physicians and Medicare federal regulation revolves
around the issue of was the care medically necessary.
Every patient contact becomes an encounter with
choice: Think first of the patient, or of the system?
It has gotten to the point where only in a minority
of cases can the two needs be met simultaneously.
I, for one, am tired of honoring the Medicare
system more than my patients' needs. I welcome the
possibility of establishing and renewing physician-
patient relationships that are not invaded by federal
rules and regulations. There are few basic truths
more fundamental than the belief that preservation
of life and liberty also includes the right to unrestricted
freedom when it comes to one's own health care.
Opting out allows the physician to place patient
care ahead of federal rules and regulations. It
empowers him to practice medicine once again.
Robert G. Schwartz, M.D., is a physician in Greenville, South
A similar version of Dr. Schwartz's opinion
article appeared in the Greenville News, January 8, 1998.