Can I bill a Medicare patient who has switched (unbeknownst to me) to a Medicare Advantage plan that I do not have a contract with?
A growing number of seniors are selecting managed care Medicare Advantage (MA) plans for their health insurance needs over traditional fee-for-service (original) Medicare. Often times, however, patients don’t fully understand how the change in plans may affect their ability to continue to see their trusted physicians.
So, what happens if your practice sees a longtime Medicare patient who has, unbeknownst to you, switched to a Medicare Advantage plan for which your physician is not contracted? Can you bill the patient? Based on information from Centers for Medicare & Medicaid Services (CMS), the answer is yes, but with limits. Physicians are limited to charging patients for Medicare covered services based on their Medicare participation status.
In simpler terms, if the physician is not contracted with a particular MA plan, but is participating with Medicare, the physician may charge the patient up to the fee schedule amount for fee-for-service Medicare. Non-participating and non-enrolled physicians may charge up to the Medicare limiting charge. If the services are not Medicare covered services (excluded) or the physician has opted out of Medicare and has met the requirements for private agreements with Medicare patients, then the physician may bill his or her usual charge to the patient.
Specifically 42 CRF 422.214, which outlines special rules for services furnished by non-contracted providers, states:
(a) Services furnished by non-section 1861(u) providers. (1) Any provider (other than a provider of services as defined in section 1861(u) of the Act) 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.
NOTE: 1861(u) providers are defined as “hospital, critical access hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, hospice program, or, for purposes of section 1814(g) and section 1835(e), a fund.”
This is also stated in CMS’s Medicare Managed Care Manual Chapter 6 – Relationships With Providers, Section 100 – Special Rules for Services Provided by Non-Contract Providers: “providers must accept as payment in full payment amounts applicable in Original Medicare.”
Chapter 6 of CMS’s Medicare Managed Care Manual also states that “non-contract providers are subject to penalties if they accept more than Original Medicare amounts."
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