Are they an advantage?

Friday, August 31, 2007

Many beneficiaries are switching from Medicare and Medicare supplements to Advantage plans. The lure of Advantage plans is that the premiums are less than the combined premiums of Medicare and supplements. Also, if a beneficiary enrolls in an Advantage plan, he is still part of Medicare, meaning the Part B premium is still paid to Medicare. Additionally, Advantage plans must provide at least the same benefits as Medicare; they can't ask for more documentation than Medicare.
But what happens to DME providers when patients switch to an Advantage plan? Many times, patients do not inform their providers of the change. DME providers discover the change when they get denials and must re-bill claims to Advantage plans. Because the plans also require a 20% co-payment, DME providers must also bill patients. Abby Block, director of CMS's Center for Beneficiary Choices, said the agency is "particularly concerned" about sales agents who do not adequately inform Medicare beneficiaries that fee-for-service Advantage plans differ from traditional Medicare. Once patients receive bills for co-payments, they inevitably call providers and ask why they must pay. DME providers must explain to patients that they are responsible for the balance, when in the past it was paid by the supplement.
A bigger problem with Advantage plans involves billing. Providers must deal with every insurance company that offers these plans and train their billers on how to recognize the differences between an Advantage plan, a Medicare supplement and traditional Medicare. Additionally, many Advantage plans ask DME providers for information not required by CMS. For example, a plan might ask providers for prior authorization before it will pay for oxygen, or a certificate of medical necessity (CMN) for a CPAP device. The Balanced Budget Act of 1997 required CMS to establish standards, regulations and rules for Advantage plans that are consistent with existing standards and regulations governing Medicare programs.
To help DME providers cope with the various Advantage plans and keep their accounts receivable from climbing higher, they need to train intake personnel to recognize these plans. Most importantly, they must not allow the plans to ask for documentation beyond what traditional Medicare requires. Providers should inform CMS if the plans continue to ask for non-required documentation.
Lee Guay is the DME coordinator for Apex of St. Peters in Helena, Mont.