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Thread: Can a dr bill a Medicare Managed Care Plan?

  1. #1

    Default Can a dr bill a Medicare Managed Care Plan?

    AAPC: Back to School
    We added a new MD to our group and he was not previously enrolled in Medicare. We have started the process of enrolling him in Medicare (months ago) with our group. We our a hospital based pathology group and we are not in network with any Medicare Managed Care Plan. We still receive payment because the hospital is in network. Can our new dr bill charges to a Medicare Managed Care Plan eventhough he is not enrolled with Medicare?

    Thank you,

  2. #2


    If he doesn't have a provider # what would you use. I don't see you getting paid.
    adrianne, cpc

  3. #3


    tomtom, did you get this from the other section?

    I'm not 100%, but for these types of plans, when you don't participate, when you agree to see that patient, you are also "agreeing to abide by Medicares terms" (or whatever that lingo is) Since you aren't par yet (w/ Medicare) I would say to wait and you should be able to retroactively bill. You should have also put an effective date on the 855 apps so your doc can retro bill for his normal Medicare patients. Just my 2 cents, but your best bet is to contact them.

    and fyi, I would never recommend "participating" w/ these medicare replacement plans - some allow you to, some don't.

  4. #4


    I reposted this topic in the General section thinking I would get more replies.

    The provider number I would use would be NPI. Right? I guess my real question is if we do get paid would this be legal? I don't want to bill claims that would seem unethical or misrepresent my Dr.
    Last edited by tomtom2; 09-24-2008 at 12:46 PM.

  5. #5


    hmmm i don't think it's unethical or a misrepresentation - your doctor provided the service - think about it, if you're participating with an insurance or not, you bill them for your docs services, right? they process how they do, and pay/deny the claim. if you feel that way... i would really call them and specifically say .. 'we're in the process of trying to get dr. smith's medicare number, will you pay for these claims when he doesn't have his medicare number yet?' if they won't, ask if you can retroactively bill. keep it plain and simple

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