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Medicare Advantage Plan- Balance billing for out of network

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roussj19

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Location
Asbury Park, NJ
My office is out of network with most insurances, but we do participate with Medicare. Once the OOP and Ded is met for the medicare advantage plans on the EOB there is no patient responsibility, but if we are out of network with the plan (e.g. aetna medicare, uhc medicare, etc) then can we balance bill? It does not seem like we can since we accept medicare, but just trying to get better clarification on the subject. Any help is appreciated~ thanks!
 
jrousseau19 said:
My office is out of network with most insurances, but we do participate with Medicare. Once the OOP and Ded is met for the medicare advantage plans on the EOB there is no patient responsibility, but if we are out of network with the plan (e.g. aetna medicare, uhc medicare, etc) then can we balance bill? It does not seem like we can since we accept medicare, but just trying to get better clarification on the subject. Any help is appreciated~ thanks!
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Medicare Advantage plans require that you follow the guidelines for the contract with the managed care organization, not with Medicare. So you may bill the patient the amount indicated on the EOB.
 
vanessamoldovan said:
Medicare Advantage plans require that you follow the guidelines for the contract with the managed care organization, not with Medicare. So you may bill the patient the amount indicated on the EOB.
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Thanks for responding. So, if patient responsibility is 0 on EOB we can not balance bill for any excess charges even though we are out of network?
 
There are certain conditions a provider must meet in order to balance bill Medicare Advantage members. If your provider was aware in advance that the patient was a Medicare Advantage member and filed the claim on behalf of the patient, then more than likely this implies a 'deemed-contracting' status, which would require your provider to accept the plan's payment determination as reimbursement in full for the services, even if out-of-network. In that case you cannot bill the patient more than was is indicated on the EOB.

If you are considering balance billing Medicare Advantage members, I'd recommend running this by a compliance specialist to ensure your provider takes the proper steps to legally do this. Here is one link that may be helpful regarding this law:
 
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