Medicare Advantage Enrollment and Credentialing
Medicare Advantage can impact enrollment, billing, and reimbursement more than many physicians realize. Learn how Part B status, network participation, and limiting charges shape compliance and help prevent costly mistakes.
Transcript:
Marc:
We get questions all the time regarding Medicare Advantage, enrollment, and Medicare Advantage; how does that tie to Medicare Part B? Does it tie to Medicare Part B? But Brandy is here with she is our COO with Practisync, and also she knows a lot about credentialing through her Rapid Credentialing connections, but Brandy, talk to us a little bit about what we run into with Medicare Advantage as it relates to Medicare Part B, as it relates to enrollment, as it relates to in and out of network. Share some wisdom with us.
Advertisement
Brandy:
Yeah, so starting at the top, Medicare Advantage, they’re the plans under your commercial products, your Blue Cross, Aetna, Cigna, that are Medicare-like plans where the patient themselves has decided, I don’t want my traditional Medicare insurance, or to use that, I want to have this other type of plan. The reason they do that is because there’s some other benefit, or believed benefit, that they’re going to get by going with the Medicare Advantage plan. So that’s the first thing is to understand the difference. The enrollment aspect is different as well, because where chiropractic is required to be enrolled with traditional Medicare, if you’re seeing Medicare patients either as participating or non-participating, you’re not required to enroll under the Medicare Advantage plans. You could be in the network and have them added to your existing contract, or you’d be an out-of-network provider.
With that being said, a mistake you don’t want to make is just assuming that if you’re out of network with Medicare Advantage, that it doesn’t matter to you, and these are cash patients, because Medicare has issued multiple publications and rules related to this, saying, “Okay, if you’re not going to be in the network with the commercial Medicare Advantage plans, you don’t have to. However, you’re still obligated to the limiting charge for covered services for those types of plans.” In other words, doesn’t matter your practice type or, you know, if you’re just primarily cash, you have to know what type of insurance your Medicare patient or Medicare well, any of your patients have, because if it’s Medicare Advantage, you have that limiting charge fee schedule for your current region you have to adhere to as an out of network provider for those covered services.
Now, of course, in network, you have the other obligations according to your contract, the fee schedule, all of that’s laid out for you, but the out-of-network, what providers originally thought was, well, this is my pass go. I’m just going to not be in network with Medicare Advantage, and I’m just going to make these cash patients while they do private pay to you. You still are limited to that rate that Medicare has for your region. So you need to make sure you know who those patients are, and you’re not overcharging them. And I know that Medicare Advantage is paying close attention to this, because in the last month, I’ve had two of them come across my desk that have gotten letters stating that the Medicare Advantage plan, the payer, is aware that the clinic is overcharging the patient based upon their Medicare Advantage status. So, something to be aware of, and just make sure that you have all of that shored up in your office so that you are getting paid properly for what you’re doing, in the best position to keep the money that you have been paid.
Marc:
Yeah, and I think you touched on two things, and I want to just kind of reiterate them a little bit, or just clarify, if we can, one is this. We’ve said this so many times, treating Medicare patients, you cannot opt out of Medicare. So you have to be enrolled with Medicare Part B to see a Medicare Advantage or a Medicare like plan, or used to be called Part C OR choice way back in the day, but Medicare Advantage plans, you can’t see them unless you were enrolled in Medicare Part B, and that’s critically important for the other reasons, I think, Brandy that you just touched on, which is how you handle it when you’re out of network with those Medicare Advantage plans. So when you’re let’s say it’s, well, let’s say it’s ABC insurance company, and you’re not in network with ABC insurance company, in that particular case, then you would still be bound by your status with Medicare Part B. So those who are non-participating with Medicare Part B would be limited in their charge up to that limiting charge maximum. But those who are participating providers with Medicare Part B then are limited with the limiting charge with Medicare, you don’t even get the extra little bit in there for that limiting charge. It’s that allowable charge, sorry, the allowable charge under Medicare participating providers. So that’s another key component. Do their limits apply to your status with Part B when you’re out of network in those cases with the Medicare Advantage plans?
What else are you, I mean? And obviously, this is an issue. I mean, you heard Brandy just say a second ago that she’s had these letters across her desk. So there are doctors who are getting a letter saying, Hey, you’re doing this wrong, and they’re doing it because they’re the patients are calling and complaining, saying, Why am I getting charged this much money and and by the way, Medicare patients, many of them, that’s what they have that many of us don’t have, which is time. So they have time to pick up the phone and call and kind of defend themselves, if you will, or to help themselves in these cases. What else are you running into in this area, Brandy?
Brandy:
Yeah, well, and even on that front, the patients are self-submitting too, because, as it’s an out-of-network patient with a commercial plan, they can self-submit, so the payer gets the super bill that shows the fee, which is not the same as the limiting charge for Medicare Advantage. And so the clinics are telling on themselves, one super bill after the next, and so it’s inevitable that that’s going to continue to happen. The other thing that I would quickly just say on the front of Medicare Advantage is in order to be eligible for a provider to be enrolled and have those Medicare Advantage products added to their existing contract. You have to first be enrolled and have a Medicare ptan. It’s that ptan that gets submitted to the commercial plan to add the Medicare Advantage products to your existing enrollment. So that’s something you want to make sure is in order, so that you are not having those Advantage Plans processing out of network or differently than you would expect. So make sure that you’re enrolled properly if you expect to be enrolled with your Medicare Advantage plans. And really, from the enrollment perspective, those are the couple of things that I would say really stand out. You want to make sure you know what plans and products you’re enrolled with. Add those additional we call them lines of business, but add those additional products so that it’s cleaner for your office, cleaner for verifying benefits, cleaner for patient communication, and helps you really know what systems upfront, upstream in your clinic that you need to implement so that you’re not overcharging from the patients.
Keep in mind too, just really quickly, and it’s sort of a on a side wheel, but when patients come in, they hand you their Medicare card and their Medicare Advantage card, right? Because they have them, they don’t know which one they need for your office, so they just give it to you, and it’s up to the clinic to determine which one needs to be billed. Now this is important, because Medicare, traditional Medicare, has a one-year timely filing. Your Medicare Advantage timely filing is going to be subject to those commercial policies. United Healthcare is 90 days, and so and the others have their own timely filing as well. So if you’re not paying attention upstream to what type of plan the patient really has and where your claim should be routed, you are dangerously close, if not already running some pretty significant risk of misrouting claims to Medicare when they really should be going to Medicare Advantage. So pay attention to your cards and make sure you’re submitting them to the claim to the proper place for reimbursement. It’s unrelated to credentialing, in the sense that you know it’s not affecting your existing enrollment, but it’s related to everything, in the sense that you’re not going to get paid, and it becomes confusing to everyone, and then your AR grows. And so a couple of things there on that Medicare Advantage topic to just keep in mind.
Marc:
Yeah, all of them are incredibly important. And if you run into roadblocks as you’re going through and you’re like, I’m running into problems with credentialing, with these groups that I want to be a part of, or whatever the case might be, maybe you’re running into problems with credentialing with Medicare, Part B standard Medicare, if you will, and you’re just running into road block after road block or delay after delay, or you’re not understanding what documents and you need some professional help, we would encourage you get some professional help. Don’t throw your time at something when you’re not able to figure it out. It’s one of the things that we have to as business people begin to realize that sometimes it’s just a whole lot easier to hire professional help to help navigate those things. Check out our Corporate Club Members. I think you’ll find that we have one that can help you out and check out Rapid Credentialing in those cases. But hopefully this helps you out, and we will catch you next week.
