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The Ins and Outs of Billing Medicare Advantage Plans
The Ins and Outs of Billing Medicare Advantage Plans
Although a Medicare Advantage (MA) plan is technically a form of Medicare coverage, it is best to view these plans in a similar fashion to your contracted commercial payers. Advantage Plans often follow the same rules for billing as regular commercial carriers.
Important Facts about MA Plans:
If you are a contracted provider for the plan the patient belongs to, and s/he asks you to bill for a service, you must do so. But, your contract with the carrier may require that you do so, regardless of whether the patient asks you to or not.
You are not required to bill the carrier if you aren’t participating and/or if out-of-network benefits aren’t available. The patient is treated as any other cash patient in your office.
Medicare Advantage Plans usually do not require the same type of Advance Beneficiary Notice (ABN) as traditional Medicare. Therefore, it’s critical when you verify each plan, you determine whether the carrier has its own ABN form that you are required to use.
Be aware of the potential problem of the patient confusing their traditional Medicare coverage with a Medicare Part C plan.
Carefully verify the current coverage to avoid billing errors. Make sure you are participating with the MA plan listed on the card. Just because you are in network with a major carrier DOES NOT mean you are in network with their MA plans.
Always ask about the out of network benefits when verifying coverage benefits. Remember, even if there are benefits, you may not have to bill.
Make sure you identify all Private Fee for Service (PFF) plans prior to submitting a bill for services, see “What is a Deemed Provider” for more details.
Summary:
Medicare’s official ABN forms (Advance Beneficiary Notice) do not apply to most Medicare Advantage Plans.
Verify insurance benefits just as you would for regular health insurance. Ask for both “in” and “out of network” benefits to determine whether or not your office is covered.
If you have a denial, recognize that the appeals process for Medicare Advantage is different from traditional Medicare appeals. Stay current on the process for each by visiting the website of the carrier for instructions.
Don’t assume plans provide chiropractic coverage. Plans may elect to eliminate DC’s. They are only required to provide services, and they can designate a DO or an MD to perform them.
DC’s are usually included in the “point of service” options.
Medicare Advantage can be a valuable option for seniors on a fixed income since the plan mirrors traditional managed care and may help keep costs down. For you, however, choose wisely before joining these networks. Make sure you verify ALL Medicare coverage for maximum efficiency; these plans may pay for otherwise statutorily non-covered services (e.g., exams and therapies). Exploring these plans to find the perfect blend of fee systems and contracted plans for your office will optimize coverage and benefits for your senior patients and result in better client relationships.
Wait there is more you need to know about Medicare Advantage Plans. Check out “”What is a Deemed Provider“” prior to billing MA plan.
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