Approximately one-third of all Medicare beneficiaries are enrolled in various Medicare Advantage (MA) programs. These plans are generally offered by insurance companies and tend to be regional. The key descriptor for these programs in that of variability. Each of these programs must cover what traditional Medicare covers, but they then generally expand from this basic coverage and add services such as dental, drugs, eyeglasses along with possibly expanded coverage for medical and surgical services. In some cases the costs of these programs is less than traditional Medicare.
For MA programs, emphasis is given to provider relationships particularly for physicians and hospitals. If a claim is filed by a healthcare provider that is not part of the MA plan’s network, then the claim is to be adjudicated under the traditional Medicare rules. Given the variability in coverage and medical policies, there can be confusion when claims are adjudicated and paid.
MA programs represent some real challenges for healthcare providers such as physicians, hospitals, skilled nursing, home health among others. In some cases, a given provider will be part of a network or under contract to the given MA plan, and, thus, coding, billing and reimbursement are governed by the contract. In other cases, a given healthcare provider may by filing a claim with an MA plan across the country in which there is no relationship between the MA plan and the provider.
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Duane C. Abbey, Ph.D. is a management consultant and president of Abbey & Abbey, Consultants, Inc., which specializes in healthcare consulting and related areas. Duane earned his graduate degrees at the University of Notre Dame and Iowa State University and has more than 20 years of experience as a consultant. He performs various types of financial analysis involving business structuring, organizational development, enrollment and other financially related concerns of organizations....
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