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Medicare Advantage claims reimbursement

By Michael G. Calahan, PA, MBA

The Medicare patient load of most physicians, regardless of specialty (with the exception of pediatrics and obstetrics), tends to be around 20 to 40 percent of a practice’s active patient base. Emerging over the last ten years or so as – surprisingly – as one of the better payers in terms of reimbursement dollars, Medicare has also cemented its position as one of the industry’s most consistent payers. Providers have come to understand Medicare payment policies better, understand the mechanisms behind getting claims paid and also understand why, in many cases, the claims have not been paid. When providers need more information on any range of Medicare topics, most are in-the-know enough to go to their carrier’s website and retrieve the information they require. Finally, the mystery seems to be dissipating. Providers no longer feel like they are sending their claims into a “black box.” But does this hold true with private payers?

With the recent proliferation of Medicare Advantage Plans (MAPs) into the payer market and the steady migration of patients leaving the traditional government-run Medicare program and entering private payer MAPs, the claims game is getting tricky again. Once again providers are being faced with denied claims, varying reimbursements for the same services, and contradictory answers to the normal range of how-to questions posed to the same payer. The level of patient participation with these plans promises to keep on its steady rise so it would be most beneficial to develop, at the beginning juncture of this phenomenon, some insight into the internal processes of the MAPs.

Without a doubt, most private payers offering Medicare Advantage products are still building a solid foundation of payment systems and policy databanks from which to adjudicate and pay provider claims both fairly and timely. These payers include major Blue Cross Blue Shield entities, nationally known plans such as Aetna, and smaller regional and local plans such as HealthNet and Geisinger. A few of these payers also currently act as Medicare Fiscal Intermediaries (for Medicare Part A) and Medicare Carrier entities (for Medicare Part B). In doing so, these plans have become divided “houses.” The internal operations are divided so that the traditional Medicare claims processing operations do not overlap into the private plan’s operations. In other words, the MAP claims are not processed by the same systems that process the traditional Medicare claims. Inevitably, while one side of the house swiftly and accurately processes, for instance, an orthopedic surgeon’s claims under regular Medicare, similar claims may hit a stumbling block in the department handling the MAP claims.

Five Things to Avoid the “Black Box” Syndrome

Communicate. Get to know the all of your MAP provider representatives. Remember many private payers are offering MAPs so the chances are that you will end up dealing with an array of actual Medicare Advantage Plans. Develop a dialogue with these service-oriented staff. The MAP teams want their policyholders (i.e., the patients) to be happy and satisfied with the insurance products as well as their provider networks – networks they are working very hard to build – to be happy with the reimbursement processes. Each Plan’s providers are a critical element to its success; the MAP teams want their providers to remain on-board, to be in agreement with their coverage policies as much as possible, and to be satisfied with the levels of reimbursement received for provider services.

Know Medicare’s Basic Policies. Most MAPs are succeeding because they exceed the basic coverage Medicare offers; to do so, they base most of their coverage policies directly off of Medicare’s policies and simply expand or exceed them. In fact, by law and for continued participation, a Medicare Advantage Plan must adjudicate out-of-state claims according to Medicare policy. Knowing Medicare’s payment policies on any number of topics germane to your practice such as noncovered services, bilateral surgical procedures, laboratory fee schedule amounts, or correct application of the -59 modifier for distinct procedural service(s), can assist you in the initial phases of claims adjudication or perhaps in establishing your case for claims under appeal.

Dispute all claims that appear to be underpaid. Many of the MAPs use Medicare reimbursement methodologies as well as benchmark Medicare’s reimbursement amounts, and simply add a certain percentage – such as five percent or ten percent – to pay provider services. It is critically important to monitor and track MAP reimbursements at this time because many of these plans are just getting off the ground, so to speak, and payment policies are being established in the here and now. In a dispute, you should know Medicare’s basic payment policy and payment amount(s) relative to the underpaid claim scenario you are presenting. You should be ready to provide supportive documentation to shore up your case, and then calmly and cogently provide your argument as to why the claim was underpaid and what you were expecting in terms of reimbursement. Use Medicare reimbursement(s) as the baseline.

Know when Medicare issues program changes and payment increases. The Medicare program is not static; it issues regular changes to policy in the form of transmittals known as Change Requests (CRs). It also updates its reimbursement schedules (e.g., physician, lab, drug and DME fee schedules) at specific junctures. These junctures can be annual, semi-annual, and/or on a quarterly basis. In many cases Medicare makes retroactive payment changes to these schedules as well. Being aware of these program updates and changes not only helps you understand the Medicare program better (and perhaps assist with compliance), but also aids in your understanding of reimbursement changes issued by the various MAPs you might be dealing with.

Track MAP Performance. Develop new tracking categories in your practice’s A/R system for all of the Medicare Advantage Plans. Because these plans will be evolving quicker than the long-established private payer plans, you will need to monitor and assess reimbursement and provider participation adjustment levels. To do this efficiently, re-categorize these plans in your system, i.e., if you track all payments and adjustments for BC/BS in one A/R category or bucket, be sure to break out from that A/R bucket that Blue’s Medicare Advantage Plan. Remember again, you will be dealing with many private payer MAPs, each perhaps offering an array of reimbursements for the same services. Be sure to set up these MAP plans into a separate A/R bucket for aggregate monitoring and tracking, and be able to break down that bucket so you can analyze how each plan is performing on an individual basis. Know the patient populations for each of the MAPs. This can assist your practice in deciding to continue to participate with each specific MAP in the future.

Michael G. Calahan, PA, MBA, is Director, Healthcare Operations & Compliance Services, Parente Randolph, LLC.

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