These plans are supposed to offer all the services that traditional Medicare offers . As a provider , you may or may not be able to participate with these plans . Technically , all Medicare providers are eligible to bill the advantage plans . However , each plan has their own rules and procedures , including their providers list . Some plans will allow any provider to bill for services , and most do not , unless you are contracted with that insuror .
In addition to somewhat limited participation , the fee schedule does not have to match that of traditional Medicare , and oftentimes it does not . Many of these plans pay significantly less than traditional Medicare , so you must make a decision if you want to work with these patients .
Medicare has several parts . Part A covers hospital expenses , part B covers physician and ancillary services ( O and P is considered an ancillary service ), part C are the Advantage plans , and Part D is the prescription drug benefit . The part C plans are alphabet soup : HMO ( health maintenance organizations ) PPO ( preferred provider organization ) PFFS ( private fee for service ), SNP ( special needs plans ) and MSA ( medical savings accounts ) comprise this soup . PPOs generally have a specific panel of providers under contract to the insuror . PFFS works like traditional Medicare in that any provider may send in claims , and SNPs are designed for the chronically ill , nursing home patients , and those with a Medicare / Medicaid in-house plan . Now , isn ’ t that clear as mud ?
MA ( Medicare Advantage ) plans may have co-pays , and traditional Medicare does not cover them . The MA is their Medicare . Enrollment follows the standard established schedule and you know when that is when the television commercials start playing . A patient can change from a MA to a traditional plan after January 1 until February 14 each year . They may not change from MA to MA . Exceptions are made for moves out of a service area or to a Nursing Home
( institutions ). Assisted Living and group homes are not considered institutions .
One very important caveat , persons on an MA plan get a standard Medicare card with their claim number on it . They also have a card from the MA . It is important to get information from both sources ; however , billings go to the MA plan . Some patients will hand you their traditional Medicare card stating that they have Medicare . You bill and the claim is denied because they have an MA plan . Make sure to ask . You can verify their coverage either through the IVR or through one of the DME MAC on-line verification services . ( Jurisdiction B : Connex ).
Claims are processed by the MA and may not be paid out of network . Claims are paid according to the contract that the MA has with CMS . It is advisable to contact the MA regarding correct coding for the services you are providing .
Appeals are handled differently from traditional Medicare . It is your responsibility to correctly submit claims to the proper address . Appeals are handled according to the plan manual . If there is a discrepancy , the first level of appeal is through the MA plan . After a second denial , the appeal is handled by MAXIMUS , a federal service provider [ www . medicareappeals . com or ( 585 ) 485-4210 ]. Non contracted suppliers are required to have a signed statement waiving liability on the part of the beneficiary holding them harmless . There is a 180 day limit from the initial notice of payment to file this appeal . The next level is to contact C2C Solutions , a company contracted to provide resolution services .
Important Considerations With MA Plans
1 . The Advance Beneficiary Notice cannot be used with a MA plan . These are usable only with traditional Medicare ; thus the necessity of the hold harmless agreement ( above ).
2 . The DME MAC has no contract with the MA plan ; contracts are between CMS and the MA plan . The regulations and procedures of the MA plan are primary .
3 . The MA plan is under no obligation to follow the standard fee schedule . Ask before you get a big surprise .
4 . The O A-24 denial code does not apply here , only under traditional Medicare .
Always consult your local DME MAC or CMS ’ s website for information about MA plans . The website of the plan is helpful to consult as well .
Some patients will be \ benefit from these plans as they tend to cover more than traditional Medicare . Rarely is there an advantage for the provider . In many cases , the reimbursement will be less ( in some plans , the A5501 payment is less than what it costs to procure the custom shoes ). Some plans pay half of the standard reimbursement to contracted providers . Be aware of these situations . Each practice will have to make a business decision on whether to accept the reimbursement from a MA plan and for what services . ■
Dean Mason , C . Ped ., OST , BOCO , CO , BOC Pedorthist , owns North Shore Pedorthics , LLC , in Lorain , Ohio , and is a member of PFA ’ s Board of Directors as co-chair of PFA ’ s Government Affairs Committee and a member of the Marketing , Communications and Editorial Committee .
Current Pedorthics March | April 2012 23