Contracted Rates with HMOs for Medicare Patients

avidsky

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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.:confused:
 

thomas7331

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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

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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.
 
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