Medicare Advantage Plans are screwing us over Non-Covered Codes
Brock Berta
Description
Collection
Title:
Medicare Advantage Plans are screwing us over Non-Covered Codes
Creator:
Brock Berta
Date:
6/1/2022
Text:
I am writing to reiterate and expand on this issue that was recently presented from a provider in Maine. This issue is national wide and will only get worse as Medicare Advantage plans become more and more popular. (42% of Medicare patients are enrolled in Medicare Advantage plans. This is up from 31% in 2016.)
The Issue:
With traditional Medicare, non-covered codes are handled using an ABN and the appropriate modifier. Medicare processes the claim as patient responsible allowing providers to bill secondary payors.
Providers cannot use ABN's with Medicare Advantage plans. Thus there are no clear rules that Medicare Advantage plans follow that lead to the appropriate patient responsible denial. Instead Medicare Advantage plans frequently deny the service as non-covered with zero patient responsibility. This leaves providers unable to bill the patient's secondary payor or the patient themselves. They are not being paid at all for these services.
With the specter of the recent OIG report Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care which showed that Medicare Advantage plans inappropriately denied 18% of claims that traditional Medicare would have covered...we must bring more attention to this issue. As Medicare is a federal program, the path can be difficult.
I suggest:
File complaints with your Medicare Advantage plan provider representatives.
Have your patients file a complaint with Medicare Filing complaints about your health or drug plan | Medicare< https://urldefense.proofpoint.com/v2/url?u=https-3A__www.medicare.gov_claims-2Dappeals_file-2Da-2Dcomplaint-2Dgrievance_filing-2Dcomplaints-2Dabout-2Dyour-2Dhealth-2Dor-2Ddrug-2Dplan&d=DwIFAg&c=sJ6xIWYx-zLMB3EPkvcnVg&r=KmuawjwNpT9A2bnhzaNVjw8wO7L_TDosEXIk33h_tlw&m=-2mymBjT4hIc7l0bk3Lj52y0BYlnYlmt9GrBm3Jna61FKk-Lw45Fz7OEl-nnKJhj&s=y1MqL5_3ntCvMBix71XeAiLyK1wacuV6qBj2EKZIqBA&e= >.
Contact your state provider association or society to see what other providers are doing.
Contact your Congressperson.
Reach out to AOPA.
We'll never get paid unless we cause a fuss.
Brock Berta Contracting Manager
Transcend Orthotics & Prosthetics, LLC
P: 574.931.7156 F: 877.206.0478
A: 17530 Dugdale Drive, South Bend, IN 46635
HIPAA Confidentiality Notice: The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of the person(s) names above. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message.
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The Issue:
With traditional Medicare, non-covered codes are handled using an ABN and the appropriate modifier. Medicare processes the claim as patient responsible allowing providers to bill secondary payors.
Providers cannot use ABN's with Medicare Advantage plans. Thus there are no clear rules that Medicare Advantage plans follow that lead to the appropriate patient responsible denial. Instead Medicare Advantage plans frequently deny the service as non-covered with zero patient responsibility. This leaves providers unable to bill the patient's secondary payor or the patient themselves. They are not being paid at all for these services.
With the specter of the recent OIG report Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care which showed that Medicare Advantage plans inappropriately denied 18% of claims that traditional Medicare would have covered...we must bring more attention to this issue. As Medicare is a federal program, the path can be difficult.
I suggest:
File complaints with your Medicare Advantage plan provider representatives.
Have your patients file a complaint with Medicare Filing complaints about your health or drug plan | Medicare< https://urldefense.proofpoint.com/v2/url?u=https-3A__www.medicare.gov_claims-2Dappeals_file-2Da-2Dcomplaint-2Dgrievance_filing-2Dcomplaints-2Dabout-2Dyour-2Dhealth-2Dor-2Ddrug-2Dplan&d=DwIFAg&c=sJ6xIWYx-zLMB3EPkvcnVg&r=KmuawjwNpT9A2bnhzaNVjw8wO7L_TDosEXIk33h_tlw&m=-2mymBjT4hIc7l0bk3Lj52y0BYlnYlmt9GrBm3Jna61FKk-Lw45Fz7OEl-nnKJhj&s=y1MqL5_3ntCvMBix71XeAiLyK1wacuV6qBj2EKZIqBA&e= >.
Contact your state provider association or society to see what other providers are doing.
Contact your Congressperson.
Reach out to AOPA.
We'll never get paid unless we cause a fuss.
Brock Berta Contracting Manager
Transcend Orthotics & Prosthetics, LLC
P: 574.931.7156 F: 877.206.0478
A: 17530 Dugdale Drive, South Bend, IN 46635
HIPAA Confidentiality Notice: The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of the person(s) names above. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message.
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Citation
Brock Berta, “Medicare Advantage Plans are screwing us over Non-Covered Codes,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/142115.
