bethb
Guru
I am located in Pennsylvania and we are having some major issues with a Medicare Advantage Plan and their methodology for muliple surgery reduction amounts. This MA is paying the primary procedure at 100%; second procedure at 50%; and third / subsequent procedure(s) at 25 % of their allowable.
This contradicts CMS guidelines for multiple surgery reductions. We have tried finding information about whether the MA has to follow CMS' guidelines-we have talked customer service reps at the plan, a provider representative for the plan and cannot get a "clear" answer. We are told by representatives from this plan that they can follow their own payment methods, thus incorporating a 25% allowance on third and subsequent surgeries, however, these reps cannot provide us with documented proof. Our physician and I both feel this is incorrect.
Can anyone shed some light on this issue? Or maybe steer me in the right direction for finding conclusive evidence?
Thanks!
This contradicts CMS guidelines for multiple surgery reductions. We have tried finding information about whether the MA has to follow CMS' guidelines-we have talked customer service reps at the plan, a provider representative for the plan and cannot get a "clear" answer. We are told by representatives from this plan that they can follow their own payment methods, thus incorporating a 25% allowance on third and subsequent surgeries, however, these reps cannot provide us with documented proof. Our physician and I both feel this is incorrect.
Can anyone shed some light on this issue? Or maybe steer me in the right direction for finding conclusive evidence?
Thanks!