Medicare challenges - provider's perspective

When Bureaucracy Stands Between Patients and Care

By Zlatoslava Karga, PMHNP, DNP

One of the greatest weaknesses of the current U.S. healthcare system is not a lack of skilled providers or a lack of patients seeking help. It is the complexity created by having multiple insurers, each with its own rules, contracts, and credentialing requirements.

When a provider opens an independent practice, caring for patients is only part of the job. To accept insurance, the provider must become credentialed separately with each insurance company. Every insurer has different applications, different requirements, different timelines, and different restrictions. Months can be spent completing paperwork instead of providing care.

This directly affects patients.

Medicare is perhaps the clearest example. Most Americans contribute to Medicare throughout their working lives. At age 65, many enroll in Medicare Part B because they have earned that benefit through years of contributions.

What many patients do not realize is that once Medicare becomes their primary insurance, their provider must also be enrolled and approved by Medicare in order to continue treating them. The enrollment process can take months, creating interruptions in care that neither the patient nor the provider anticipated.

Even more surprising is that Medicare patients often cannot simply choose to pay privately while a provider is waiting for enrollment approval. Many patients assume they can pay cash and continue treatment with the clinician they trust. In reality, Medicare rules are far more restrictive.

There are circumstances in which Medicare beneficiaries may pay privately, but those situations generally require the provider to formally opt out of Medicare and comply with additional federal requirements. This creates another layer of paperwork, reporting obligations, and administrative oversight for providers who choose that path.

As a result, both patients and providers can find themselves trapped in a system where the desire to continue care exists on both sides, yet administrative rules make that continuity difficult or impossible.

From an administrative perspective, patients can simply be directed to another provider.

From a mental health perspective, it is not always that simple.

Mental health treatment depends on trust, continuity, and therapeutic relationships built over time. Patients struggling with depression, anxiety, trauma, cognitive difficulties, or other psychiatric conditions are often vulnerable. Changing providers is not merely changing a name on an insurance directory. It means retelling painful histories, rebuilding trust, and starting over during a time when stability may already be fragile.

A simpler system is possible.

Universal coverage for basic medical and mental health services would allow patients to focus on receiving care rather than navigating insurance networks. Providers could focus on treating patients rather than spending months completing separate credentialing processes for multiple insurers.

Healthcare should prioritize access to care and continuity of care. When a patient needs help and a qualified provider is available to provide it, administrative barriers should not stand between them.

The purpose of healthcare is care. Our systems should reflect that principle.

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