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 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 103.
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When providing covered services to MA enrollees, chiropractic physicians fall into one of the following categories:
Contracted Provider with a Medicare Advantage Plan
A contracted provider agrees (within the contract) 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. Any additional amount is considered covered by the plan.
Your Medicare participation status does not apply when you are contracted with the MA plan. Instead the contract dictates the terms.
Non-Contracted Provider with a Medicare Advantage Plan
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.
The MA plan is responsible for reimbursing the provider the difference between the enrollee’s cost-sharing and the original Medicare limiting charge.
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.
