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Medicare Replacement Plans

  1. Default Medicare Replacement Plans
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    For billing Medicare Replacement Plans (HMO's, etc), are offices required to utilize the Medicare fee schedule for those covered services or since Medicare Replacement Plans are outside Medicare jurisdiction, are those offices allowed to bill at their standard fees? If anyone has the answer to this that would be excellent. Also, I am hoping for a written reference for my records, if you know where that can be found.

    Thank you.

  2. #2
    On the back of some of those plan's ID cards it has verbiage about if a doctor agrees to see the patient it "deems" the provider to accept their fee as payment in full (& not balance bill the patient).

    Maybe others will have more info about the plans & what is/isn't allowed when it comes to billing the patient....

  3. #3
    Medical Billing
    Your contract with each particular plan should indicate which rules you should follow. First refer back to your contract. Where we are (St. Louis area) most of the Medicare Advantage plans do follow Medicare's guidelines because these patients are still Medicare eligible patients. For example, one of our payers has a commercial line as well as a Medicare Advantage plan. The payer rules are different depending on whether the patient is under the commercial plan (consult codes can be billed) or the Advantage plan (consult codes cannot be billed). I don't have the link to the CMS website but I believe there is a section that addresses this issue.

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