So you think you don’t “participate” with Medicare Advantage Plans? Think again…

 In Articles, Medicare Quality Programs, News

If you are a Medicare provider and you agree to provide services to a patient covered by an out-of-network Medicare Advantage Plan, you are agreeing to accept Medicare rates for those services and therefore may not balance-bill the patient for your full fee.

Say what?!?

According to the federal regulations that establish and govern the Medicare Advantage Program, non-contracted providers who participate with original Medicare MUST accept as payment in full what the provider could collect under original Medicare. (42 CFR § 422.214(a)(1))

But the patient’s plan didn’t actually pay anything to my practice!

You may bill the patient the Medicare rate in full, but you may not charge them your full fee.

So then, what’s the difference between Medicare Advantage Plans and Private Fee-For-Service (PFFS) plans?

From the provider reimbursement standpoint, very little.

Why is it like this?

Medicare Advantage was created with the purpose of saving Medicare money while protecting and expanding Medicare beneficiaries’ rights and choices. The Program is not aimed at benefiting medical providers. As a provider, by opting-in to original Medicare, you agreed to the rules that pertain to Medicare Advantage as well.

Is there any way to avoid this?

If you opted-in to original Medicare, the only way to avoid accepting Medicare rates for Medicare Advantage patients is to not to see those “out-of-network” Medicare Advantage patients. You cannot privately contract around these rules on a patient-by-patient basis unless you opt out of Medicare completely (for a minimum of two years). However, if you are a “non-participating” provider with original Medicare, you can charge 15% above the Medicare allowable.

42 C.F.R. Section 422.221(1) specifies: “Any provider . . . that does not have in effect a contract establishing payment amounts for services furnished to a beneficiary enrolled in an MA coordinated care plan, an MSA plan, or an MA private fee-for-service plan must accept, as payment in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare.”

If you have any questions about any of these options or changing your status with Medicare, please contact MSOC Health.

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