Treating Patients Enrolled in Medicare Advantage Plans

With so many Medicare beneficiaries now enrolled in Medicare Advantage plans, providers who treat these patients need to know the fine print in how they work. There are Medicare Advantage plans that are HMOs and PPOs and even some that are “private fee-for-service plans” (PFFSPs). Since there are only a few PFFSPs, and the rules surrounding them are not as clear as the rules for the HMOs and PPOs, this article will address only HMOs and PPOs.

If You Are an Enrolled Medicare Provider

If you are enrolled as a Medicare provider but are not in a Medicare Advantage plan’s network, you have several choices. If the patient has a Medicare Advantage plan that does not allow reimbursement for out-of-network providers, you are not bound by the Medicare fee schedule unless you choose to be.

If the Advantage plan allows its enrollees to go out of network, you can choose to be a “contract provider” and accept the fee the Advantage plan pays, or you can choose to be a “noncontract provider” and be paid what you would have received if the patient was a fee-for-service Medicare patient.

There is, however, a third choice. Even though you are a Medicare provider, you are permitted to see the patient as if he or she did not have Medicare coverage and charge your usual and customary fee (or whatever fee the two of you agree to). If you choose this third option, you are advised to have a contract with the patient to ensure that the patient understands that neither Medicare nor Medicare Advantage fees apply to the care you are providing and that the patient is obligated to pay your fee no matter how he or she is reimbursed by the Advantage plan.

If You Are Not Enrolled as a Medicare Provider

Although you are not permitted to provide care to a fee-for-service Medicare beneficiary unless you are enrolled and can file claims with Medicare as a provider (or have entirely opted out of Medicare), this rule does not apply for beneficiaries who have chosen to receive Medicare services through an Advantage plan. These patients have effectively opted to receive their care outside of Medicare, and since claims are not filed with Medicare, you do not have to be on the Medicare books to see these patients. There is one caveat: If you have been banned from the Medicare program for any reason, you cannot provide care to Medicare beneficiaries even if they are in Medicare Advantage plans.

Since some patients may not understand the terms of their Advantage plans, it is essential that you make it clear how your reimbursement will be determined: whether you will file claims for them with their plan; whether you will accept whatever fee the plan offers with whatever copay is provided; or whether you do not want to have any relationship with their plan and will require them to pay the agreed-upon fee and seek any reimbursement from their Advantage plan on their own. Of course, whatever you choose to do, you must provide patients with the necessary paperwork to file claims on their own.

Have a question or comment on insurance, Medicare, or other practice-related issues? Contact APA’s Practice Management HelpLine at (800) 343-4671 or [email protected].