Insurance Agent Forum

[honestagent]

A recent thread provoked me to ask this and before I go calling on a few doctors' offices or call inadequate broker hotlines, I thought I'd ask you professionals on here hoping you would know the answer to my questions.

I am wondering can doctors opt not to accept an MA claim for certain procedures even though he accepts a PFFS plan at the time of procedure / service?

For example, Dr. Smith accepts Secure Horizons and Mrs. Jones went in for a MRI. Okay, so we know that Doctors can drop an MA at any time at will. But, can they choose what they will or will not accept or is everything covered on an MA plan if they accept the Part C MA plan accordingly dictated by the carrier's EOC and Medicare guidelines?

This is where the smut of the smut will pervade. Thank you.

[midwestbroker]

According to Humana's provider relations, doctors can accept the PFFS payment plan on a case by case basis. They are not contracted, but they are deemed (accept the payment conditions and terms).

But, from what I know, if they accept the PFFS plan, it is all or nothing. They cannot pick and choose what they will or will not accept.

Now, this is where it gets fun...

If your doc takes the PFFS, that does not mean the MRI facility will take it. So, you have to make sure all the providers involved will take the plan.

Major metros with HMO's and PPO's usually do not have this problem. The rule of thumb is that if they take the HMO / PPO from one company, they will take the PFFS from the same company. If you are in a PFFS only market, that is where you get the accepting issues.

My advise, get the provider intro letters from the carrier and fax them / take them to the provider (usually a intro letter, billing info, etc). Some even have the electronic billing number in there.

[somarco]

If your doc takes the PFFS, that does not mean the MRI facility will take it. So, you have to make sure all the providers involved will take the plan.

That is the case with any managed care plan. More often than not clients fail to take into account the hidden providers who are free to charge whatever they wish and you are obligated to pay as billed.

[honestagent]

Midwest, good stuff. Thanks for highlighting this for me. Somarco, thanks for your added valued opinion too. I greatly appreciate it. It's really important to know. Thank you.

[Dave020]

I guess it must vary by plan design. I was talking to CA BC the other day about MAPD PPO (Freedom Blue) and they told me that it functions just like all other PPO plans, and that they likely have separate negotiated rates for the providers above what Medicare allows. So I guess, and correct me if I am wrong, it would break down like this:
-MA HMO - doctor accepts negotiated rate
-MA FFS - doctor may accept or request higher reimbursement
-MA PPO - doctor has negotiated fee rate with carrier
Dave

[midwestbroker]

Somarco -

With most MA plans, the client has a fixed co-pay for services, if the doctor accepts the plan. So, the client will be out no more then the co-pay listed in the Summary of Benefits. At least, that is what I have found. I will almost bet though that there are some that are looking for every loophole there is to bill more.

Dave -

HMO and PPO docs have a contract with the carrier for services. PFFS doctors have to agree to the payment terms and conditions. Most PFFS plans that I have seen are 100% of the Medicare allowed rate. I am sure there are others out there that may vary.

[Dave020]

Thanks, that it what I was thinking.
Dave