Wiki Medicare billing and Managed care medicare

[sgruly]

If a provider is in network with Medicare but not a managed care plan (Aetna medicare or Anthem Medicare) is the provider allowed to bill the patient for the full charge or do we have to bill the pt the Medicare's contracted rate?
Also if the provider isn't in network with the managed care plan can we bill Medicare?
Thanks
Stacey

 

[thomas7331]

Under CMS regulations, if the provider is aware in advance of the patient's participation in the Medicare managed care plan, treats the patient and submits the claim on behalf of the patient, then the provider is 'deemed' to have accepted the terms of that patient's plan and must legally abide by the payment terms and accept the contracted rates - the patient cannot be balance billed. With a couple of very limited exceptions, such as when the patient is enrolled in a hospice program, you cannot bill claims for managed care Medicare patients to regular Medicare - they will be denied with a remark code stating that the claim should be filed to the managed care payer instead.

 

[sgruly]

Thank you! That's what I thought. But a I was told that we can bill medicare instead of the Managed care plan and that we can bill the patient the additional charges beyond medicare's contracted rate. She said she called Medicare and they told her we can bill the patient our charge amt (which is more than the contracted amount)