APMA News - September/October 2017 - 38

Reimbursement

Medicare Advantage: Frequently Asked Questions
APMA receives numerous questions related
to Medicare Advantage (MA) plans. This article
highlights some of the most common questions and directs members to APMA resources
to help them further understand their rights
and responsibilities related to MA plans.
Do MA plans have to cover the same benefits as Original Medicare?

1 There is an exception from the latter requirement that allows
plans that include multiple Medicare Administrative Contractors
within their service area to adopt a uniform Medicare coverage
policy with CMS approval. Plans doing so must make information
on the selected LCDs available to providers and members.
38 APMA News September/October 2017

I keep getting requests for multiple medical
records from MA plans. Can I charge for copying or
other costs/labor involved in responding to these requests?
Physicians who receive requests for chart reviews from an
MA plan should refer to their contract with the requesting
plan to understand their rights with respect to such reviews.
Some contracts may give the physician certain rights such as
limiting audits to reasonable business hours and giving the
physician adequate notice to produce the charts. If the MA
plan requesting the chart review is a PFFS plan and the physician does not have a written contract with the plan, he or
she should refer to the plan's terms and conditions. A physician is deemed to accept these terms and conditions whenever he or she provides non-emergency services to an individual known to be a plan member. The terms and conditions are
available on the plan's website.
If there is no obligation to provide the records to the MA
plan for this purpose, or if the contract is silent on payment,
then the physician might want to ask for payment for the
time and work involved in responding to the request. In addition, if the number of records or other aspects of the request
are a large burden, plans can generally be flexible with timelines
and other logistics. The physician can call the plan and propose
an alternative or otherwise request some type of relief from
large medical record requests.

Can an MA plan prohibit me from billing a patient for noncovered services?
MA plans generally place restrictions on contracted physicians' ability to bill for non-covered services. Most frequently,
they require that contracted physicians first obtain an organization determination (like a prior authorization decision)
that clearly states the service is not covered. This requirement
is based on CMS guidance to MA plans stating that Advance
Beneficiary Notices may not be used for MA enrollees. Instead,
MA plans must notify members of non-coverage through
an organization determination in order for the member to be
held liable for the service. Physicians' billing rights and responsibilities for non-covered services may be set forth in the contract or in the plan's policies and procedures. As long as the
physician follows the plan's procedures, he or she should be
able to bill for non-covered services.

Question marks graphic by Shutterstock/Alexey Painter.

The short answer is yes. MA plans are required to cover
the same items and services as Original Medicare. They must
follow national coverage determinations (NCDs) and general
Medicare coverage guidelines, and they must generally follow
the written local coverage determinations (LCDs) applicable
to the geographic area in which the services were furnished.1
The requirement to cover the same services as Original
Medicare, however, does not mean plans must pay their contracting providers in the same amount and manner as Original
Medicare. Medicare law does not address the amount an MA
plan must pay its contracting providers for furnishing covered
services. Payment arrangements are considered a private contractual matter between the provider and the MA organization.
Moreover, MA plans are free to adopt their own coding, editing,
and bundling policies consistent with the payment terms set
forth in their provider contracts. MA plans are also authorized
to impose utilization review mechanisms, such as prior authorization requirements, not imposed under Original Medicare.
Medicare law does address payment to non-contracted providers who furnish covered services to MA members, including providers who furnish emergency or out-of-area urgently
needed services. It also includes non-contracted providers
who furnish services to a member of an MA PPO and providers who furnish services to members of non-network MA private fee-for-service (PFFS) plans. Medicare law requires that
MA plans pay these providers the same amount they would
have received under fee-for-service Medicare for furnishing
covered service to their members. Thus, for these non-contracted providers, the plans must follow the coding policies-
including recognition of modifiers-of Original Medicare.
If a physician believes an MA plan is not covering services
that are covered under Original Medicare, he or she should look
at the reason for non-coverage stated on the applicable EOB. A
statement that the item or service(s) is not a covered service
would indicate the plan may not be meeting its obligation to

cover Original Medicare benefits. A statement
that the service is not medically necessary
would require further research to determine
whether the decision is consistent with any
applicable NCDs or LCDs.

Table of Contents for the Digital Edition of APMA News - September/October 2017