Wiki Contracted Rates with HMOs for Medicare Patients

[avidsky]

Can anyone tell me if a participating Medicare provider is prohibited by CMS to be contracted with an HMO at greater than 100% of Medicare's allowed amount? (specifically for Medicare patients that have an HMO)
I know this pertains more to the billing side of things but I am not finding an answer anywhere.

 

[thomas7331]

Medicare Advantage plans are allowed to negotiate contracts with providers for rates higher than regular Medicare - I'd refer you to the Medicare Managed Care Manual on the CMS web site. From Chapter 4 of the manual:

"MAOs may negotiate payment amounts with their contracted providers and need not follow original Medicare payment rates. However, in the absence of a mutual agreement between the non-contracted provider and the MAO to receive less than the original Medicare rate, non-contracted providers must accept the original Medicare amount as payment in full."

 

[avidsky]

Thank you

Medicare Advantage plans are allowed to negotiate contracts with providers for rates higher than regular Medicare - I'd refer you to the Medicare Managed Care Manual on the CMS web site. From Chapter 4 of the manual:

"MAOs may negotiate payment amounts with their contracted providers and need not follow original Medicare payment rates. However, in the absence of a mutual agreement between the non-contracted provider and the MAO to receive less than the original Medicare rate, non-contracted providers must accept the original Medicare amount as payment in full."

Thank you for the info and guidance. Much appreciated.