Georgia Medicare Physician Services: Costs & Assignment

Two things decide what a Georgia beneficiary pays to see a doctor under Original Medicare: whether the annual Part B deductible is met, and whether the doctor accepts Medicare assignment. In 2026, you pay the first $283 of covered physician charges yourself, then Medicare pays 80% of the approved amount and you (or your Medigap plan) owe the remaining 20%.1

Georgia Medicare physician services are covered under Medicare Part B and paid through the Medicare Physician Fee Schedule. The single most useful question you can ask before booking a non-emergency visit is whether the physician is a participating Medicare provider who accepts assignment. If they do, they cannot bill you more than the Medicare-approved amount. If they do not, a legal cap called the limiting charge still protects you, and if they have opted out of Medicare entirely, you pay the full fee yourself. This guide explains those costs and protections, the federal framework behind them, and how to find a participating doctor across Georgia.

How Georgia Medicare Physician Services Work: What You Pay

Physician services sit at the center of Medicare Part B. CMS describes Part B's scope as physicians' services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services Part A doesn't cover.5

Because physician services fall under Part B, they carry Part B cost-sharing. In 2026, you pay the annual Part B deductible of $283 before Medicare starts paying its share for most physician services; after the deductible is met, Medicare pays 80% of the Medicare-approved amount and you owe the remaining 20% coinsurance. A Medicare Supplement (Medigap) policy typically covers that 20%. Plans C and F also cover the Part B deductible, but they can't be sold to people new to Medicare on or after January 1, 2020; if you were eligible for Medicare before that date, you may still be able to buy one.1,6

Coverage also turns on medical necessity. Part B covers medically necessary services, meaning services or supplies that meet accepted standards of medical practice to diagnose or treat a medical condition, along with preventive care.5 Where Medicare has no national rule for a service, the regional contractor can issue a local coverage determination deciding whether that service is reasonable and necessary, and therefore covered, under Section 1862(a)(1)(A) of the Social Security Act.7

Does Your Doctor Take Medicare Assignment? PAR, Non-PAR, and Opt-Out

Under Medicare's physician-payment rules (Social Security Act Sections 1842 and 1848, implemented at 42 CFR 414.20 through 414.48), how much you pay a doctor in Original Medicare depends on the physician's participation status and whether they accept assignment. There are three statuses, and knowing which one applies is the difference between a predictable 20% coinsurance and an unexpected balance bill.2

Participating (PAR). A participating physician signs a Medicare participation agreement and accepts assignment on every Medicare claim. They are paid the full Medicare Physician Fee Schedule amount, must submit the claim to Medicare for you, and may charge you only the Part B deductible and 20% coinsurance. They cannot balance-bill above the approved amount. Most doctors accept assignment, but it isn't universal, so check that yours does.2

Non-Participating (non-PAR). A non-participating physician is still enrolled in Medicare but has not signed the annual participation agreement. Their fee schedule amount is, by law, 95% of the participating amount (the "5% reduction"). A non-PAR physician can take assignment claim by claim; when they do, they collect only the deductible and 20% coinsurance on that reduced amount. When they do not take assignment, you can be charged up to the limiting charge, may be asked to pay the full charge up front, and Medicare reimburses you (not the physician) its 80% share.2

Opt-Out (private contract). An opted-out physician privately contracts with each Medicare patient, and Medicare makes no payment for the services covered by that contract. The contract must say that you accept full responsibility for the doctor's charge and that Medicare will not pay, and the limiting charge does not apply.2 The exception is emergency or urgent care: if an opted-out doctor treats you in an emergency and you had no private contract with them beforehand, they must bill Medicare and can charge no more than the limiting charge.8 Medigap does not cover opt-out physician services.3 Opt-out is common in concierge medicine and some specialty practices, and an opt-out runs in two-year periods that renew automatically unless the doctor cancels.8

The Limiting Charge: Your Protection Against Balance Billing

The limiting charge, set in federal regulation at 42 CFR 414.48, is the ceiling on what a non-participating physician can bill you for an unassigned service: 115% of the non-PAR fee schedule amount. Medicare frames the same rule for beneficiaries as, in many cases, "no more than 15% above the Medicare-approved amount." Because the non-PAR amount is itself 95% of the participating amount, the cap works out to roughly 109% of the full participating fee schedule. A bill above the limiting charge is more than the doctor may charge you, and if a non-participating doctor refuses to send the claim to Medicare, you can submit your own claim.2 For help with a bill, call 1-800-MEDICARE (1-800-633-4227).9

The Federal Framework Behind Medicare Physician Services

Most coverage and billing questions resolve to one of a handful of federal provisions. Understanding the backbone helps you recognize where a given rule comes from.

Who Counts as a "Physician"

The Social Security Act's definition of "physician" in Section 1861(r) reaches beyond medical doctors; it includes doctors of optometry, for example, for the services their state licenses them to perform.10 Each type of practitioner has its own coverage scope:

• Doctors of medicine or osteopathy (MD/DO), the primary category, covering the full range of medical and surgical services.
• Doctors of dental surgery or dental medicine (DDS/DMD), but only for the narrow services a physician could perform. Most dental care is not covered under Original Medicare.5
• Doctors of podiatric medicine (DPM) for covered foot and ankle services. Routine foot care, such as nail trimming and removing corns or calluses, is generally not covered unless a qualifying condition, such as diabetes, has caused severe circulatory problems or reduced sensation in the feet.11
• Doctors of optometry (OD) for services they are licensed to perform, such as glaucoma screening for people at high risk.10
• Chiropractors for the most limited scope of all: only manual manipulation of the spine to correct a subluxation. X-rays a chiropractor takes or orders, and the other services a chiropractor furnishes, are not covered.12

How the Medicare Physician Fee Schedule Sets Payment

Medicare pays physicians from the Medicare Physician Fee Schedule (MPFS), under the physician-payment rules in Sections 1842 and 1848 of the Social Security Act.2

Payment for a service equals the sum of three Relative Value Units (RVUs), each adjusted for local costs, multiplied by a national dollar conversion factor:

Payment = [(Work RVU x Work GPCI) + (Practice Expense RVU x PE GPCI) + (Malpractice RVU x MP GPCI)] x Conversion Factor

The Work RVU measures the physician's time, skill, and effort; the Practice Expense RVU measures overhead; the Malpractice RVU measures liability insurance cost. The three Geographic Practice Cost Indices (GPCIs) adjust each component for local cost differences, and the Conversion Factor, set annually by CMS, turns RVUs into dollars.

For calendar year 2026, CMS finalized two conversion factors for the first time: a qualifying-APM-participant factor of $33.57 and a non-qualifying factor of $33.40, both up from the single 2025 factor of $32.35. CMS attributes the increase to three pieces: a statutory update of 0.75% for the qualifying factor and 0.25% for the non-qualifying one, which the law sets for 2026 and each later year, a one-time 2.5% boost that applies to 2026 only and won't carry into 2027, and an estimated 0.49% adjustment for changes to work RVUs.13

The Quality Payment Program: MIPS and Advanced APMs

Medicare also adjusts what it pays some clinicians through its Quality Payment Program, which has two tracks:

• The Merit-based Incentive Payment System (MIPS), which sets reporting requirements and payment adjustments for clinicians eligible for it.
• Advanced Alternative Payment Models (Advanced APMs), such as some Medicare Shared Savings Program ACOs. A clinician who meets a payment or patient threshold through an Advanced APM becomes a Qualifying APM Participant (QP), is excluded from MIPS reporting and payment adjustments, and, beginning with payment year 2026, receives a higher fee schedule conversion factor update than other clinicians.14

That higher update is why 2026 has two conversion factors, the $33.57 one for QPs and $33.40 for everyone else.13

The Stark Physician Self-Referral Law

The Physician Self-Referral Law, known as the Stark Law (42 U.S.C. 1395nn), bars a physician from referring a patient for "designated health services" to an entity that the physician or an immediate family member has a financial relationship with, unless an exception applies. It is a strict-liability statute, and its penalties include fines and exclusion from federal health care programs. It binds physicians and other providers, not patients.15

Finding Georgia Medicare Physician Services: Providers, Claims, and Contacts

Georgia beneficiaries reach physician care through hospital-employed groups, independent multi-specialty clinics, academic medical centers, and Federally Qualified Health Centers, which serve patients on a sliding-fee scale statewide.

Palmetto GBA, Georgia's Medicare Contractor

Palmetto GBA is the Medicare Administrative Contractor for Jurisdiction J Part B, covering Georgia, Alabama, and Tennessee. It processes physician claims and also handles first-level appeals (redeterminations), provider enrollment, customer service, and medical review. A denied claim doesn't end with Palmetto, though: the redetermination is the first of five appeal levels, and the second, a reconsideration, goes to a Qualified Independent Contractor that took no part in the first decision.4

How to Confirm a Physician Takes Assignment

Before a non-emergency visit, take three steps. First, use Medicare Care Compare to search participating physicians by location and specialty. Second, ask the practice directly whether they accept Medicare assignment for your specific service, because a non-PAR physician can decide claim by claim. Third, if you are ever charged more than the limiting charge, don't pay the excess, and call 1-800-MEDICARE for help.9 Free, unbiased help is available from GeorgiaCares, the state's Medicare counseling program.16

How Georgia Beneficiaries Access Physician Services: Worked Examples

These examples illustrate how the framework above applies to common situations. Names and details are hypothetical and illustrative.

Example #1: A participating internist in Atlanta

Margaret, age 78, sees a participating internist at a Piedmont primary care practice for an established-patient office visit. Because her doctor participates and accepts assignment, she pays the Part B deductible at her first covered service of the year, then Medicare pays 80% of the approved amount directly to the practice. Her Medigap Plan G covers the remaining 20% coinsurance, so after the deductible she has no additional out-of-pocket cost, and the doctor cannot balance-bill her.1

Example #2: A non-participating dermatologist in Savannah

Robert, age 82, sees a non-participating dermatologist in Savannah who does not accept assignment for the visit. The dermatologist may bill him up to the limiting charge, and Medicare reimburses Robert (not the physician) its 80% share of the non-PAR fee schedule amount. Robert's out-of-pocket is the gap between the limiting charge and the Medicare reimbursement. Had he seen a participating dermatologist who accepts assignment, his cost would have been 20% of the approved amount, or nothing after his Medigap coverage. He decides to ask about assignment before his next referral.2

Example #3: A chiropractor's limited coverage in Columbus

Patricia, age 73, has chronic low back pain and visits a chiropractor. Medicare covers only the manual manipulation of her spine to correct a subluxation, and only while it is corrective treatment expected to improve her condition rather than maintenance.12 That manipulation is subject to the Part B deductible and 20% coinsurance.1 Medicare pays nothing toward the X-ray and massage the chiropractor also provides; what she owes for those depends on any other insurance she has, what the chiropractor charges, and whether the chiropractor accepts assignment.12 She learns to ask what anything beyond the manipulation will cost before agreeing to it.

Example #4: An opt-out concierge doctor in Athens

Henry, age 85, has seen the same concierge primary care physician for years, but that doctor has opted out of Medicare. Henry can stay under a private contract, paying the doctor's full fees plus an annual membership out of pocket, with Medigap providing no coverage for those visits, or he can transfer to a Medicare-participating primary care physician and pay only 20% coinsurance after the deductible, which his Medigap covers. His emergency, hospital, and specialist care stay covered by Medicare regardless, because only his primary doctor is opted out. He chooses to stay, valuing the relationship and accepting the cost.2,3,17

Common Mistakes to Avoid

1. Assuming every physician takes Medicare. Some have opted out, especially in concierge medicine and certain specialties. Confirm participation status before a non-emergency visit.

2. Confusing participating with non-participating. Participating physicians accept assignment on all services; non-participating physicians can balance-bill up to the limiting charge. Always ask whether the doctor accepts assignment.

3. Not knowing the limiting-charge protection. A non-participating physician who doesn't take assignment cannot charge more than the limiting charge, which Medicare describes as, in many cases, no more than 15% above the Medicare-approved amount. If charged more, don't pay the excess, and call 1-800-MEDICARE.2

4. Believing Medicare covers all chiropractic care. Coverage is limited to manual spinal manipulation for a subluxation; X-rays and other services from the chiropractor are not covered, though a spine X-ray that a medical doctor (MD or DO) orders, takes and reads to check for a subluxation can be.12

5. Believing Medicare covers routine dental or foot care. Most dental care is excluded,5 and routine foot care is generally not covered absent a qualifying medical condition.11

6. Forgetting the Part B deductible. The 2026 annual deductible of $283 applies before Medicare starts paying its share for most physician services.1

7. Forgetting that opt-out physicians do not work with Medigap. When a physician opts out, Medigap does not apply and you pay the full fee.3

8. Assuming Medicare Advantage uses the same rules. MA plans negotiate their own physician rates, use provider networks, and may require prior authorization. Verify network status before scheduling.

Learn More

Find personalized help confirming whether your physician accepts Medicare assignment at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.