Out of Network MAPD PPO, No Balance Billing?

[yorkriver1]

The MAPD PPO evidence of coverage aka: the actual policy document for both Humana and Aetna says that when getting treatment by in or, --interesting--also out of network providers, the providers aren't allowed to balance bill.

I assume that if the provider is billing Aetna or Humana the insurance carrier won't pay the bill if the provider is going to balance bill the patient, even if done under the rules of Medicare for providers who choose to balance bill.

Any deep knowledge suggestions here? We can call the billing and claims folks at carrier, mixed results in my experience.

 

[somarco]

Assuming the MCO agreement has similar language, where is the hammer to prevent non-par providers from balance billing.

 

[MBSC]

From the Medicare Managed Care Manual, Ch.4.

Section 50.5 – Guidance on Other Enrollee Out-of-Pocket Liability

No balance billing: As indicated in section 170 below, an enrollee is responsible for paying non-contracted providers only the plan-allowed cost-sharing for covered services. The MA plan, not the enrollee, is obligated to pay balance billing when it is allowed under Medicare rules. Furthermore, if an enrollee inadvertently paid balance billing which is the plan’s responsibility, the plan must refund the balance billing amount to the enrollee.

Section 170 – Balance Billing
When enrollees obtain plan-covered services in an HMO, PPO, or RPPO, they may not be charged or held liable for more than plan-allowed cost-sharing. Providers who are permitted to ‘balance bill’ must obtain the amount in excess of the enrollee’s cost-sharing (the balance) for services, directly from the MAO and not from the enrollee.

Section 170.2 – Balance Billing by Provider Type
The rules governing balance billing as well as the rules governing the MA payment of MA-plan contracting providers, non-contracting providers and original Medicare participating and non-participating providers are listed below by type of provider.
• Contracted provider: There is no balance billing paid by either the plan or the enrollee.
• Non-contracting, original Medicare, participating provider: There is no balance billing paid by either the plan or the enrollee.
• Non-contracting, non-(Medicare)-participating provider: The MAO must pay the non-contracting, non-participating (non-par) provider the difference between the enrollee’s cost-sharing and the original Medicare limiting charge, which is the maximum amount that original Medicare requires an MAO to reimburse a provider. The enrollee only pays plan-allowed cost-sharing.
• MA-plan, non-contracting, non-participating DME supplier: The MAO must pay the non-contracting non-participating (non-par) DME supplier the difference between the enrollee’s cost-sharing and the DME supplier’s bill; the enrollee only pays plan-allowed cost-sharing.

 

[yorkriver1]

Thanks for the replies, and detailed info from Medicare. I think it will be important to talk to someone at the carrier, since the client wants to know their share of the cost of the surgery, and I don't want to give information I can't control or know is correct.

I am concerned about who to contact at the carrier to get a good answer, but maybe I don't need to. Seems like a good idea to step back and tell the client to have the docs ask the carrier for approval.

The EOC described a form of pre-approval for out of network procedures, called a "pre visit coverage decision". Seems like a good idea. EOC: "You never need approval in advance for out-of-network services from out-of-network providers.
While you don’t need approval in advance for out-of-network services, you or your doctor can ask us to make a coverage decision in advance."
The EOC mentions that services could be determined to be ineligible after the fact, so getting them approved up front seems pretty important.

re: the excess charges--What the EOC's don't mention, if I read the 3rd bullet right from the Managed Care Manual above, is that the MAPD pays the excess charges if services are provided by a non-par (allowed to balance bill within limits) Medicare provider. My client wanted to know if his surgeons would be allowed to charge excess charges. If Aetna will pay them, then it's all good for client and surgeon. I got the impression from the EOC that they wouldn't be allowed to charge excess charges at all. The point seems to be, the provider can charge excess, but the patient is contractually excluded from the obligation to pay them.
If the plan pays them, then excess charges wouldn't count towards the $10,000 maximum out of pocket, I assume.

Aetna EOC, Chapter 4, section 2.1, excerpt:
"If you receive the covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for participating providers.
o
If you receive the covered services from an out-of-network provider who does not participate with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for non-participating providers."