Medicare Part C/Advantage Plans Have Rules—Please Follow Them!

Hot Topics from the KMC University HelpDesk

So many calls to our HelpDesk revolve around questions about these privately managed Medicare plans. Some providers and team members have never even heard of these plans. Cash-based practices are often confused because it’s Medicare, but is it really? Understand each of the three subcomponents of Medicare Part C. Follow the rules for the plan you verify that your patient has. KMC explains these rules, and what you can charge in each situation.

Video Transcript:

Hi there. It’s Kathy Weidner also known as Kathy Mills Chang and I thought I would come to you from the KMC University HelpDesk today to answer a question that’s been coming in pretty regularly over the past several weeks and it’s about Medicare Part C/Advantage plans. Sometimes they’re all so known as Medicare replacement plans, but these are the plans where the patient has decided not to go with Part B under the government’s hospice, but rather choose a private payer

One of the biggest mistakes that people make is thinking that they don’t have to verify this. The main reason is that when someone is in a Medicare Part C/advantage plan, they could be in an HMO a PPO or a PFFS, private fee for service. And only after you verify their plan can you know that and then decide how do I handle it. If you are a participating provider, you need to know if you’re participating provider in either the PPO or HMO or both and what about PFFS? Well. You don’t have to accept that patient. But if you’re out of network and you are in a PFFS plan, you don’t have to accept them. You can refer them elsewhere. Now. What do you do about the patient who has let’s say Aetna Managed Medicare and you are not a part of that plan?

Well, it used to be that we would tell you treat them as cash. It’s okay. Well, we’ve in about a year ago found out that’s not the case anymore. It is not the same as any other cash paying patient, but for active treatment AT modifier worthy care of the spine one would need to treat that patient the same as any other Part B patient. meaning that if you are participating in Part B, then the maximum fee would charge for this AT modifier Part C care directly from the patient would be the allowed amount non-participating the limiting fee now, you may not have to submit that. It may be a cash transaction or self-paid transaction, but you wouldn’t know that unless you verify and make certain that there are no other rules that are affiliated with that. So, what can I charge a Medicare Part C/advantage plan patient? The simple answer is it really depends? So, step one make sure you verify all your Medicare Advantage patients step two know your participation status in these plans. If you are in otherwise cash-based practice, chances are you’re not participating with them in that case follow your Part B rules. The last point that has come up so many times recently. What do I do about an ABN? Well, they’ve made it clear you do not use the traditional ABN from Medicare Part B. Rather instead. You should have your own special notice or check in with the payer to see if they have their own form, they’d like you to use. these are all the parts of doing business with people who have Medicare Advantage or Medicare Part C. More questions? Don’t hesitate to contact us. If you’re a KMC University member Be sure you email the HelpDesk and we’ll be delighted to help you. Not a member? You can always purchase a little bit of time with one of us on demand and we’ll be happy to help.

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