Understanding Balance Billing for Chiropractic Physicians and Medicare Advantage (MA) Plans
Navigating Medicare Advantage (MA) rules can be complex, particularly when it comes to understanding billing practices, modifiers, balance billing, cost-sharing, and the rights and obligations of providers and patients. Recently, members have asked us how much they can bill Medicare Advantage patients for covered services.
What is Balance Billing?
Balance billing occurs when a healthcare provider bills a patient for the difference between the provider’s charge and the amount covered by the insurance plan. Under Medicare Advantage (MA) plans, balance billing rules for covered services differ depending on the provider’s contracting and Medicare participation status. The Medicare Managed Care Manual Chapter 4 – Benefits and Beneficiary Protections covers this information on page 102-104.
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The short answer is this: When providing Medicare-covered services to a MA plan patient, providers are not permitted to collect more than the patient’s cost-sharing specified by the plan.
When providing covered services to MA enrollees, chiropractic physicians fall into one of the following categories:
Provider Contracted with a Medicare Advantage Plan (MA Network Provider)
A contracted provider agrees (within the MA provider agreement) to accept the MA plan’s payment terms and cannot bill the patient for any amount beyond the cost-sharing specified by the plan (such as copayments or coinsurance).
Patients are only responsible for the copay or coinsurance set by the MA plan, and the MA plan is responsible for the remaining amounts up to the plan-established rates. You are not allowed to balance bill the patient.
Your Medicare participation status does not apply when you are contracted with the MA plan. Instead, the contract dictates the terms.
Provider Not Contracted with a Medicare Advantage Plan (Out of MA Network)
If you are a Participating Provider with Original Medicare:
A chiropractic physician who participates in original Medicare but does not have a contract with the MA plan cannot balance bill the patient.
However, the Managed Care Manual indicates, “Participating providers may never balance bill because they have agreed to always accept the Medicare allowed amount as payment in full,” and providers must “obtain the amount in excess of the enrollee’s cost sharing (the balance) for services, directly from the MAO and not from the enrollee.” From these statements, it appears that the MA plan should cover up to the Medicare-allowed amount for your region.
Unfortunately, some MA plans may interpret the document to indicate that they are only required to pay non-contracted but Medicare-participating providers the plan rates instead of the Medicare-allowed amount.
In either case, you are not able to balance bill the patient, and the patient pays only the copayment or coinsurance amount allowed by the plan.
If you are a NON-Participating Provider with Original Medicare:
An original Medicare non-participating provider (non-par) who has not signed a contract with the Medicare Advantage plan can bill patients up to the Medicare limiting charge but cannot exceed that amount.
The MA plan pays the difference between the enrollee’s cost-sharing and the original Medicare limiting charge.
The enrollee is only responsible for the plan’s allowed cost-sharing, which may be:
- A copay amount determined by the plan.
- A coinsurance percentage multiplied by the limiting charge if the plan uses a coinsurance method.
Important Reminder: Chiropractic Physicians Cannot Opt-Out of Medicare
It is important to note that chiropractic physicians cannot opt out of Medicare. The opt-out provision, which allows certain types of providers to enter into private contracts with Medicare beneficiaries, does not apply to chiropractic physicians. This means that all services provided by a chiropractic physician to a Medicare beneficiary must be billed to Medicare or the patient’s MA plan if they are enrolled in one.
