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We follow Medicare guidelines, they say

We follow Medicare guidelines, they say

Many Medicare beneficiaries are being enticed by celebrities on TV to select a Medicare Advantage (MA) plan over original Medicare fee for service (FSS) with all the standard benefits of Medicare at a lower out-of-pocket cost. These plans often state they provide additional benefits, such as gym memberships, transportation and eyeglasses, so how can they provide more benefits with a lower cost? Seems too good to be true, doesn't it? How can these private, for-profit insurance companies provide more for less, pay all these celebrities to promote their insurance on TV and make a profit? While some of these plans are able to do this with the increased number of members, thus spreading the costs over a larger pool, others, from what suppliers are experiencing, are able to do this by not actually providing the same benefits as original Medicare.

When suppliers encounter a customer that has a Medicare Advantage plan, they must determine if they have to be in network if required and the coverage policies. Many plans inform their customers, as well as the suppliers, that they “follow Medicare guidelines.” Most would take this that they will cover and process claims the same as original Medicare would. However, while these plans are required at a minimum to furnish all medically necessary Medicare-covered DME (policy), they are not required to follow Medicare's payment rules (prices, rental/purchase, modifiers, clean claim timeliness, etc). Clarification of this long standing outstanding question was recently received from CMS. So this appears to be the other way these plans can promote that they offer more for less because they can reduce the prices for DME and pay them in a different manner that saves them money (rental over purchase). 

All suppliers need to be aware of this and take this into consideration when determining if they can accept a contract/ customer with one of these MA plans. It is vital to obtain their policies and payment rules in writing prior to accepting a customer so you know what you are getting into. If they verbally say, “We follow Medicare,” ask them what that means. Ask if they follow Medicare's policies (coverage) and payment rules and try to get this in writing prior to agreeing to provide DME to these customers.
Here is a section of the information received from CMS regarding Medicare Advantage plan requirements:

“While MA plans are required to furnish all medically necessary Medicare-covered DME, they are not required to follow original Medicare payment rules in furnishing those services. MA plans will generally furnish MA enrollees with all medically necessary DME through contracted DME suppliers. Since MA plans are capitated by CMS, the MA plan is financially responsible for furnishing all medically necessary, Medicare-covered services, which of course includes DME items and supplies. In addition to their financial and coverage responsibilities, MA plans have the ability to negotiate prices with their contracted providers and also to use utilization management tools consistent with Medicare coverage standards.”

What this means is if an MA plan determines that it is best for them to rent complex rehab power wheelchairs rather than extending the purchase option that is available to original Medicare beneficiaries, they can do that. They can negotiate reimbursement prices, as well, and from what providers are experiencing, some are also denying accessories that original Medicare allows per policy. A recent widespread example: electronics (E2377, E2311 and E2313).

Providers need to be aware of these other ways MA plans can provide more for less, while incurring the costs of all those commercials with celebrities. This other way squeezes the DME supplier and is impacting access, as more and more suppliers are saying no to contracts or customers with one of these plans.

What can you do?

First, review all contracts thoroughly and make sure it's clear what they pay and how they pay (rental/purchase). Don't just accept, “We follow Medicare guidelines,” because that doesn't mean they follow Medicare's payment rules since they are not required to per CMS. If you can't accept what they offer, don't. Try to negotiate a fair contract and if they won't, don't accept it.

Second, educate MA plan customers that you can't accept their insurance and the reason why. They are only hearing from celebrities promoting their plans of how great they are, but not how they negatively impact their true medically necessary benefits with unsustainable prices and payment methods (13 month rental for complex rehab power wheelchairs and accessories). While the MA plan customer may be able to get a gym membership and eyeglasses, they may not be able to obtain the wheelchair they need. Educate them that they can select original Medicare FFS (switch back), if they find that the MA plan isn't as good as the celebrities made it appear.

Please notify Medicare recipients struggling with making sense of all these plans and their sales pitches that they can call 1-800-633-4227 (1-800-Medicare) to speak to a Medicare representative for accurate unbiased information about selecting the best plan for them.

Dan Fedor is the director of reimbursement and education for U.S. Rehab, a division of VGM. Reach him at [email protected].


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