Gastroenterology Coding Alert

Hint: Coverage rules may vary quite a bit from Part B guidelines.

If it feels like you’re seeing an increasing number of patients with Medicare Advantage (MA) instead of traditional Medicare plans, then you’re correct. About 34 percent of all Medicare beneficiaries were enrolled in at least some type of MA plan last year, and that number is expected to rise to nearly 50 percent over the next decade.

That was the word from WPS Medicare’s Aileen Sigler during the MAC’s February 25 presentation “Medicare Advantage: How Does It Affect You?”.

The WPS team shared several tips that can help your GI practice optimize payments from MA insurers, so read on for the scoop.

1. It’s Not A Secondary Plan

An MA plan is an alternative to Medicare’s traditional Part A and Part B programs — rather than being a supplemental or secondary policy. With a supplemental policy, a patient is covered by Medicare Parts A and B, and then also gets a secondary, supplemental policy to pay for out-of-pocket costs that Medicare won’t cover. An MA plan, on the other hand, replaces Parts A and B. Medicare Administrative Contractors (MACs) do not process MA claims. You’ll instead send MA claims to the Advantage contractor.

2. Coverage Should Follow Traditional Medicare Regs

MA plans must provide beneficiaries with all original Medicare services covered by Medicare Part and Part B except for hospice, assuming the patient is eligible for both Parts A and B, Sigler said. However, not all of the same rules will apply.

For instance, some MA plans might cover a screening colonoscopy as Part B would, but the MA payer may require the patient to get a referral to the gastroenterologist first.

3. Not All MA Plans Are the Same

You may be familiar with the nuances that vary among Part B MACs, but that’s nothing compared to how different MA plans can be. One patient may have an MA plan that’s an HMO, while another could have a PPO, Sigler said. A third patient may be enrolled with a private fee-for-service MA plan. The key is to know which type you’re dealing with when an MA patient presents to your practice.

4. It’s the Practice’s Job to Determine Coverage

Determining whether a patient is insured under MA, traditional fee-for-service Medicare, a supplemental policy, private insurance, or any other options can be challenging, but it’s up to your practice to make that determination, said WPS’ Thom Ryan during the call.

“Medicare says providers must determine who to bill in order to bill accordingly,” he advised. “This means you have to start with the card.” However, be careful when you use the term “Medicare card,” since some patients may not equate MA or Part B with “Medicare.” So you should also ask them “Do you have any other insurance cards?” in addition to the Part A card they may present.  

Once you get the cards, examine them to see which are current, and then evaluate which insurance plans the patient has. If a patient knows they have other insurance but isn’t sure what it is, you’ll have to try and track that information down. “It is not acceptable to automatically bill Medicare,” he said. Do your homework first.

5. MA Plans Must Have the Means to Handle Appeals and Other Functions

Each MA plan must handle overpayments, appeals, enrollments, and support functions, as well as a contact center where you can get answers. Therefore, if you have questions about these issues, go directly to your MA payer rather than your Part A or Part B payer.

6. Issues Like ABNs, Payment Guidelines Are up to Insurers

MA plans may set their own payment guidelines and rules. For instance, the question of whether to use an Advanced Beneficiary Notice (ABN) is unique to each MA plan, Ryan said. “Some don’t use them at all, some may say you don’t need them if you’re out of network, others might say they request a different form. So we do recommend contacting the plan to see how they’re using it,” he advised.