# Medicare Advantage Plan vs CMS



## bethb (May 21, 2013)

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!


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## bwolfe1 (May 21, 2013)

Your question interested me so I did a "google" and found this example:

(But refer to your provider contract for specifics) 

"When a provider reports a surgical procedure/service that Regence considers eligible for MSR on the same day as another procedure that Regence considers eligible for MSR, all procedures eligible for MSR are ranked by fee schedule amount and an appropriate reduction applied to each code. The reductions used at Regence are:  100%, 50%, 25%, 25%, 25%, etc…..

Regence follows the American Medical Association (AMA) CPT guidelines and the CMS Multiple Procedure Indicators in determining which codes are eligible for MSR.  Regence considers surgical codes with CMS Multiple Procedure Indicators of 2 and 3 eligible for MSR. Regence considers codes which AMA CPT flags as “Modifier 51 Exempt” or as “Add-On” not eligible for MSR. When AMA and CMS conflict, AMA guidelines take precedence."

http://www.or.regence.com/provider/...modifier-51-and-multiple-procedure-logic.html


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