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What is a Medicare Provider?
Just the Essentials...
In short, a Medicare provider agrees to payment from Medicare for medical services and supplies.
With that said, we can also consider pharmacies, hospitals, surgeons, doctors and nursing staff as Medicare providers.
In order to pay its providers, a Medicare beneficiary must receive the services or supplies.
Likewise, providers who accept Medicare can offer physical, occupational and speech therapies
Not to exclude mental and behavioral health, Medicare providers may be clinical psychologists or psychiatrists.
Importantly, Medicare only covers services and supplies deemed medically necessary, which excludes dental work, eye exams, hearing aids, alternative medicine, or cosmetic surgery.
Many people assume that a Medicare provider only refers to doctors. In reality, providers include a whole host of other medical professionals, facilities, and supply vendors.
You can think of Medicare providers as medical professionals, facilities, or vendors of medical supplies who enter a contract with Medicare.
On one end of the contract is Medicare, which ensures standards of care and offers compensation to providers for specific services and supplies. On the other end of the contract are Medicare providers. Because of Medicare’s financial strength, many providers across the nation accept assignment from Medicare. In effect, this means many millions of patients covered by Medicare give providers plenty of work.
Whether they’re doctors, pharmacies, hospitals, or other facilities, enter your zip above to start a free custom quote using your own providers.
Prosthetic and Orthotic Devices
The design and fitting of artificial limbs and braces to help support missing or weakened areas of the body are called prosthetic and orthotic medical services.
As with any Medicare provider, the supplier must accept assignment from Medicare. If so, Medicare Part B covers various medical supplies when needed for patients to improve mobility and quality of life.
Prosthetic and orthotic providers can offer:
Artificial arms and legs
Knee and ankle braces
Hand, knee and arm braces
Back braces
Neck braces
Other orthotic mobility devices
Mobility Products
If you are injured or disabled, then your ability to move becomes crucial to your independence. Mobility supplies can come from suppliers who accept Medicare assignment.
Despite typical connotations, Medicare providers are not always doctors. They can be other medical professionals or businesses, like vendors of durable medical equipment.
Medicare providers of durable medical equipment can offer mobility products like:
Wheelchairs
Canes
Crutches
Tub and bed lifts
Shower chairs
Bedside commodes
Walkers
In order to cover mobility equipment, Medicare providers assess the need for items used to relieve difficulty walking, sitting or standing for long periods of time.
In some situations, patients require rehabilitative therapies or need longer periods of recuperation than the hospital will allow. Many of the Medicare providers of durable medical equipment also provide hospital beds for home use.
Pharmaceuticals
Prescribed medications have increasingly become an essential part of health maintenance in times of serious illness, or with ongoing conditions. Medicare Prescription Drug Plans use a “formulary” to list covered drugs, separating them into price categories.
These lists are set each year, but are subject to change at any time due to new research or the introduction of generic alternatives, for example. In general, the lowest prescription prices lie the lowest category.
If a drug that is most effective is only available in a higher category an “exception” can be made to give you the lesser amount co-pay.
Durable Medical Supplies for Use At-Home
Providers of durable medical supplies for use with patients at home must confirm that the equipment will last at least three years and is medically necessary for the health of the patient. This requires orders from the attending physician.
Medicare will cover the costs for medically needed items such as:
Blood sugar monitors and test strips
Suction pumps
Continuous passive motion machine (CPM)
Infusion pumps and necessary supplies
Nebulizers and medication
Oxygen equipment
Sleep apnea and Continuous Positive Airway Pressure devices and accessories (CPAP), and more
Hospital Stays, Surgery, Doctor or Clinic Visits
Any type of hospital service is covered if you have Medicare Part A.
Part B covers other medical services such as doctor and clinic visits, physician assistant visits, surgeries and other types of outpatient procedures deemed necessary by the doctor. Each separate entity and medical personnel is a provider to those with qualified Medicare coverage.
Nursing Homes and In-Home Nursing Assistance
A temporary stay at a nursing home might be necessary when you require complete care and friends or family cannot provide.
Medicare will NOT pay for long-term nursing care, but it will pay for brief periods of nursing care and home health care.
Other financial arrangements have to be made in cases where the patient requires complete care for the rest of their lives. Medicare will also help cover the costs of in-home nursing assistance when it is considered more beneficial than hospitalization.
Diagnostic Testing
To be sure, staying healthy and determining what ails you can require diagnostic testing. Depending on your medical needs, your doctor might use various tests to help make a definitive diagnosis.
Medicare providers can perform tests including:
X-rays
EEG
EKG
Heart stress tests
CT scan
MRI
Blood tests
Blood glucose tests
Urinalysis
Biopsies, and more
Once your test results are in, the doctor can better recommend and start a course of treatment.
Clinical Psychologists and Psychiatrists
There are providers in the mental health arena as well. Staying mentally fit is an essential part of living a happy and productive life at any age.
The need for a provider of psychiatric or psychological services can strike at any age, and can be an ongoing condition that needs routine treatments.
Mental and behavioral services can include diagnosis and treatment for:
Depression
Anxiety
Stress
Dementia/senility
Schizophrenia
Bipolar/ADHD
PTSD, and more
Physical and Occupational Rehabilitative Services
For a number of reasons, a patient might need therapists who specialize in exercise that helps regain and maintain mobility.
Providers of these services must do so out of medical necessity.
Physical and occupational rehabilitation might be needed in cases of:
Serious body trauma (such as a serious vehicle wreck)
Post-surgery
Stroke
Amputation
Blood clot
Neurological disease
Chronic pain
Speech Pathology
In any situation, the ability to communicate is crucial to independence. With that in mind, speech pathologists offers services to help improve speech abilities after events like:
Strokes
Brain Aneurism
Head or neck Trauma
Throat surgery
Medicare will help cover the costs if it is a medical necessity and requires skilled therapy to treat. Of course, Medicare sets limits on the frequency and duration of speech pathology treatments.
Health Screening Services
In general, treating illness has greater success when problems are caught earlier than later. This is especially true in cases involving cancer and conditions of the heart.
Health practitioners and facilities that offer screening services for Medicare recipients can be Medicare providers. Basically, this means Medicare will compensate them an agreed-upon amount for different types of testing.
When it comes to preventative testing, Medicare Part B covers screenings at no out-of-pocket cost.
What Medical Service or Product Outlets Would NOT Be Considered a Provider?
Overall, the vital services or products covered by Part A or Part B Medicare require one main thing:
In order for Medicare to cover medical service or supply, your attending physician must declare it medically necessary for your health and well-being.
While many of us consider certain items and services crucial, if the Medicare provider doesn’t consider it a medical need, then Medicare won’t cover it.
Commonly, a few things excluded from provider care involve:
Eye exams for glasses
Most types of dental services
Dentures and partials
Cosmetic surgery of any type
Acupuncture and other alternative medical services
Hearing aids and exams
Any medical supply, device, treatment, or drug that is NOT deemed medically necessary
Overall, the most important thing to remember is that you need the backing of your doctor to make things happen.
Building a lasting and trusting relationship with your healthcare providers helps you make the most of your Medicare benefits through a network of strong and caring providers.
Enter your zip below to find the right Medicare provider for you; we use a simple but comprehensive search algorithm that matches your personal information with qualified Medicare health insurance companies in your state.
