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 are the backbone of Medicare Part B and the largest category of outpatient Medicare spending. Section 1861(q) of the Social Security Act (codified at 42 U.S.C. 1395x(q)) defines "physicians' services" broadly as professional services performed by physicians, including surgery, consultation, and home, office, and institutional calls. Section 1861(s)(2)(A) is the clause that brings those services into Part B coverage.

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 pays anything toward 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%, and some Medigap letters also cover the Part B deductible.1

Every service must also be "reasonable and necessary for the diagnosis or treatment of illness or injury" under Section 1862(a)(1)(A). That medical-necessity standard is the foundation under all physician coverage, whatever the specialty.

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 Medicare-enrolled physicians are participating.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 takes no Medicare payment at all. Medicare will not pay for their services except in an emergency, you are responsible for the full cost under the private contract, and the limiting charge does not apply. Medigap does not cover opt-out physician services. Opt-out is common in concierge medicine and some specialty practices, and the opt-out runs in two-year, renewable periods.

The Limiting Charge: Your Protection Against Balance Billing

The limiting charge under Section 1842(g) 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 "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. If a physician charges you more than the limiting charge, you can refuse to pay the excess and file a complaint with Palmetto GBA; physicians who violate it can face sanctions.2

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"

Section 1861(r) defines five categories of practitioner as a "physician" for Medicare purposes, each with its own coverage scope:

• Doctors of medicine or osteopathy (MD/DO) authorized to practice medicine and surgery under state law. This is 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 routine dental care is not covered under Original Medicare.
• Doctors of podiatric medicine (DPM) for covered foot and ankle services. Routine foot care is generally not covered absent a qualifying condition such as diabetes with peripheral neuropathy.
• Doctors of optometry (OD) for services they are licensed to perform, such as diabetic eye exams and glaucoma screening.
• Chiropractors for the most limited scope of all: only manual manipulation of the spine to correct a subluxation. X-rays performed by chiropractors and other modalities are not covered.

The Medicare Physician Fee Schedule and RBRVS

Section 1848 establishes the Medicare Physician Fee Schedule (MPFS) under the Resource-Based Relative Value Scale (RBRVS), added by the Omnibus Budget Reconciliation Act of 1989 and effective January 1, 1992. It replaced the older "customary, prevailing, and reasonable" charge method, which paid procedural specialties far more than cognitive ones for the same time.

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. The change reflects a statutory one-year update of 2.50% plus a small budget-neutrality adjustment.3

MACRA and the Quality Payment Program

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, Public Law 114-10), signed April 16, 2015, permanently repealed the Sustainable Growth Rate formula, which had tied physician payment updates to gross domestic product and forced Congress into 17 temporary "doc fix" patches between 2003 and 2015. MACRA replaced it with the Quality Payment Program, which has two tracks:

• The Merit-based Incentive Payment System (MIPS), under Section 1848(q), scores clinicians across four performance categories (Quality, Cost, Improvement Activities, and Promoting Interoperability) and applies a positive or negative payment adjustment two years after the performance year. MIPS is budget-neutral, so positive adjustments are funded by negative ones.
• Advanced Alternative Payment Models (Advanced APMs), under Section 1833(z), reward clinicians who bear financial risk in models such as the Medicare Shared Savings Program and use certified electronic health record technology. Qualifying APM Participants are exempt from MIPS and, beginning in 2026, receive the higher of the two conversion factors above.

None of these adjustments appear on your bill. MIPS and APM incentives change what Medicare pays the practice, not your cost-sharing.

The Stark Physician Self-Referral Law

Section 1877, the Stark Law, prohibits a physician from referring a patient for certain "designated health services" (clinical lab, physical/occupational/speech therapy, imaging, radiation therapy, durable medical equipment, home health, outpatient drugs, and inpatient and outpatient hospital services) to an entity in which the physician or a family member has a financial relationship, unless a regulatory exception at 42 CFR 411.353 through 411.357 applies. Stark is a strict-liability statute, meaning intent is not required, which is why compliance drives how Georgia practices structure their in-office lab, imaging, and therapy arrangements.

Finding Georgia Medicare Physician Services: Providers, Localities, 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 and Georgia's Two Localities

Palmetto GBA is the Medicare Administrative Contractor for Jurisdiction J Part B, covering Georgia, Alabama, and Tennessee. It processes physician claims, issues Local Coverage Determinations, conducts medical review, and administers participation enrollment. Reach Palmetto GBA at 1-877-567-9230.

Georgia is split into two Medicare fee-schedule localities: Locality 1 (Atlanta), the Atlanta metropolitan area, which carries higher GPCI values reflecting higher local costs, and Locality 99 (Rest of Georgia), every county outside that area. The same procedure is paid at a slightly higher rate in Atlanta than in rural Georgia because of the GPCI adjustment, and beneficiary cost-sharing is proportionate.

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, refuse the excess and file a complaint with Palmetto GBA. Free, unbiased help is available from GeorgiaCares, the state's Medicare counseling program.4

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. Under Section 1861(r), Medicare covers only manual manipulation of the spine to correct a subluxation. Of the services she receives, only the spinal manipulation is covered, subject to the Part B deductible and 20% coinsurance; the chiropractor's X-ray, separate evaluation, ultrasound, and massage are not covered, and she pays those in full. She learns to budget for the narrow scope of Medicare chiropractic coverage.1

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

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 cannot charge more than 15% above the Medicare-approved amount. If charged more, refuse the excess and file a complaint with Palmetto GBA.2

4. Believing Medicare covers all chiropractic care. Coverage is limited to manual spinal manipulation for a subluxation; X-rays and other modalities are not covered.

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

6. Forgetting the Part B deductible. The 2026 annual deductible of $283 applies before Medicare pays anything toward 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.

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.