Medical Billing Forum

Billing => Billing => Topic started by: Billing2 on January 18, 2018, 01:01:17 PM

Title: Medicare Advatage
Post by: Billing2 on January 18, 2018, 01:01:17 PM
I need help on Medicare Advantage.

Here is what the problem is.  My provider is out of network with the insurances. (Aetna BCBS). So why can't he bill them a full fee for his services?  I've always understood that Medicare advantage follows the same guidelines as Medicare. He is a Medicare provider.

Is that the rule or can we charge the full fee?
Title: Re: Medicare Advatage
Post by: Michele on January 19, 2018, 06:50:45 AM
Each Medicare Advantage Plan has it's own guidelines/rules about out of network providers.  From what I read on CMS they encourage the patients to verify if a provider is in network with their plan and state that their costs will be much less if they use in network providers.  It doesn't state anywhere that patients can't go to out of network providers or that the providers have any limit to the charges.

Anybody else have any information on this?
Title: Re: Medicare Advatage
Post by: PMRNC on January 19, 2018, 02:32:34 PM
Quote
It doesn't state anywhere that patients can't go to out of network providers or that the providers have any limit to the charges.

Just because a provider is a Medicare provider, if they are out of network and it's an HMO then the patient would be responsible for charges. If it's just a PPO or POS plan the patient can go to a provider in or out of network and the full fees can be billed. Just keep in mind they may only pay Medicare rates anyway. You can bill normal charges however.
Title: Re: Medicare Advatage
Post by: danibrittany64 on February 23, 2018, 04:50:39 AM
If you chose a Medicare Advantage Plan instead of the traditional Medicare, then you’ll have to follow their guidelines as well. You must visit only those doctors who are within the network of your Medicare Advantage Plan. They are specific regarding the doctors or hospitals you visit.