decisionhealth Newsletters, Part B News - 2007 Issue 1 (January)
Pay hinges on ‘deemed' vs. ‘non-contract' MA services
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Article Overview
This article reviews Medicare Advantage payment issues that can arise when patients move from traditional Medicare to Medicare Advantage coverage. It is aimed at physicians, billing staff, and practice managers who need a general understanding of how plan status, access to plan information, and CMS guidance affect payment arrangements and provider responsibilities. The article also discusses the role of private fee-for-service plans, related Medicare Advantage plan types, and practical considerations for avoiding misunderstandings about coverage and payment.
Why This Topic Matters
Understanding whether a patient encounter falls into a deemed or non-contract situation can affect how a practice is paid and what obligations it may have under Medicare Advantage plan rules. The article helps readers identify the broad compliance and reimbursement implications of treating MA enrollees.
Article Sections
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Overview of Medicare Advantage payment scenarios
Introduces the payment issue that can arise when a patient transitions from fee-for-service Medicare to Medicare Advantage coverage. Summarizes the general distinction between two provider status scenarios discussed in the article.
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Doctor may be ‘deemed’ physician
Explains the setting in which deemed status may arise and describes the Medicare Advantage plan type most associated with this issue. Also references CMS guidance and plan terms and conditions as part of the discussion.
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How to tell the difference between deemed and non-contract
Outlines the factors the article says are used to distinguish between deemed and non-contract situations. Discusses the general circumstances, including emergency and enrollment-verification issues, that are addressed in CMS guidance.
What You Will Learn
- How Medicare Advantage plan enrollment can affect physician payment scenarios
- The general distinction between deemed and non-contract provider status
- Which broad Medicare Advantage plan types are discussed in connection with payment handling
- Why CMS guidance and plan-access considerations matter to providers
- What types of practice situations may affect whether a provider is considered to have prior knowledge of coverage
Who Should Read This
- Physicians
- Medical billers and coders
- Practice managers
- Revenue cycle staff
- Healthcare compliance staff
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