decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Medicare Managed Care / Payment Rules for Medicare HMOs
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Article Overview
This article covers Medicare managed care payment rules for HMOs and how they differ from fee-for-service Medicare in common billing situations. It is intended for coders, billing staff, and practice administrators who need a high-level understanding of how plan participation, patient status, and hospital payment methods affect claim handling. The discussion addresses emergency care, voluntary out-of-plan services, physician reimbursement context, and how payment responsibility may shift when a beneficiary moves into an HMO during an inpatient stay.
Why This Topic Matters
Medicare managed care rules can change who is financially responsible for services and how claims should be handled at the time care is furnished or coverage changes. Understanding these general payment principles helps practices and hospitals avoid misbilling and account for plan-related payment differences.
What You Will Learn
- How Medicare HMO payment rules differ from traditional Medicare billing arrangements
- How emergency services and voluntary out-of-plan care are addressed under managed care
- How hospital and physician payment responsibility may be affected when coverage changes during an inpatient stay
- How managed care status can affect reimbursement considerations for participating and nonparticipating providers
Who Should Read This
- Medical coders
- Billing staff
- Practice managers
- Revenue cycle professionals
- Hospital billing departments
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