Page 12 - Mobility Management, January/February 2021

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Medicare Advantage Plans
They Say They Follow Medicare Guidelines, But...
By Dan Fedor
Many Medicare beneficiaries are being solicited by private insurance companies offering Medicare Advantage Plans via TV commer- cials. These Medicare Advantage Plans pose as Medicare, and some of them even use celebrities to pitch their product. Read the fine print, as they are not affiliated with Medicare.
They are trying to convince Medicare beneficiaries to select their “Advantage Plan” over original Medicare Fee for Service (FFS) by stating they offer all the standard benefits of Medicare with a lower out-of-pocket cost.
But wait, there’s more: These plans often state they provide additional benefits, such as gym memberships, transportation and eyeglasses. How can they provide more benefits with a lower cost? How can these private, for-profit insurance companies run all these TV commercials and pay celebrities and make a profit?
Electronics E2377, E2311 and E2313 are frequently being denied as not medically necessary
While some of these plans are good for the beneficiary’s needs
and are fair to suppliers with reim- bursement, many are not. Some offer more for less due to an increased number of members, thus spreading the costs over a larger pool. Many others are able to do this by not providing the same benefits as orig- inal Medicare.
Many of these plans don’t follow
Medicare’s payment rules, and some attempt to pay for Complex Rehab Technology (CRT) wheelchairs on a rental basis, deny expensive elec- tronics that are necessary to operate power positioning, and deny payment, thus plunging the CRT supplier into the labyrinth of appeals.
Do Medicare Advantage
Plans Really Follow Medicare Payment Rules?
When suppliers encounter a customer who has a Medicare Advantage Plan, they must deter- mine if they have to be in network if required, and they have to figure out the coverage policies. Many plans say “We follow Medicare” — and most would take this to mean that the Medicare Advantage Plan 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).
Suppliers need to be aware
of this so they can take this into consideration when determining
if they can accept a contract or customer with one of these Medicare Advantage Plans. If you’re a CRT or DME supplier, is vital to obtain the Medicare Advantage Plans’ policies and payment rules in writing prior
to accepting a customer so you know what you are getting in to. If the Medicare Advantage Plan says, “We follow Medicare,” ask what that means. Ask if they follow Medicare’s policies (coverage) and payment
rules. And get their policies and payment rules in writing prior to agreeing to provide DME to these customers.
What CMS Actually Says
The Centers for Medicare & Medicaid Services (CMS) says this about Medicare Advantage Plans: “While Medicare Advantage 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. Medicare Advantage Plans will generally furnish Medicare Advantage enrollees
with all medically necessary DME through contracted DME suppliers. Since Medicare Advantage plans are capitated by CMS, the Medicare Advantage plan is financially responsible for furnishing all medi- cally necessary, Medicare-covered services, which of course includes DME items and supplies. In addi-
tion to their financial and coverage responsibilities, Medicare Advantage plans have the ability to negotiate prices with its contracted providers and also to use utilization manage- ment tools consistent with Medicare coverage standards.”
This means if a Medicare Advantage Plan determines 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 judging by what suppliers are experiencing, some Medicare Advantage Plans are also denying accessories that original Medicare allows per policy. A recent
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