Medicare Advantage and OON Questions and Answers
Lately, I have been receiving questions from providers who are not contracted with Medicare Advantage plans and who want to know if they can evaluate and treat those patients and charge them cash. In this article, I will answer the following questions:
- I’m enrolled in the Medicare program as a participating provider and not enrolled with the Medicare Advantage (MA) plan. The MA plan does have out-of-network (OON) benefits. Must I submit a claim to the MA carrier and are there limitations in how much I can charge the patient?
- I’m enrolled in the Medicare program as a non-participating provider and not enrolled with the Medicare Advantage (MA) plan. The MA plan does have OON benefits. Must I submit a claim to the MA carrier and are there limitations in how much I can charge the patient?
- I’m not enrolled in the Medicare program and not enrolled with the Medicare Advantage (MA) plan. The MA plan does have OON benefits. Must I submit a claim to the MA carrier and are there limitations in how much I can charge the patient?
- I’m enrolled in the Medicare program as a participating provider and not enrolled with the Medicare Advantage (MA) plan. The MA plan does not have OON benefits. Must I submit a claim to the MA carrier and are there limitations in how much I can charge the patient?
- I’m enrolled in the Medicare program as a non-participating provider and not enrolled with the Medicare Advantage (MA) plan. The MA plan does not have OON benefits. Must I submit a claim to the MA carrier and are there limitations in how much I can charge the patient?
- I’m not enrolled in the Medicare program and not enrolled with the Medicare Advantage (MA) plan. The MA plan does not have OON benefits. Must I submit a claim to the MA carrier and are there limitations in how much I can charge the patient?
Lets Begin!
Question #1
I’m enrolled in the Medicare program as a participating provider and not enrolled with the Medicare Advantage (MA) plan. The MA plan does have out-of-network (OON) benefits. Must I submit a claim to the MA carrier and are there limitations in how much I can charge the patient?
Answer #1 The content here is for members only log in here or sign up. Question #2 I’m enrolled in the Medicare program as a non-participating provider and not enrolled with the Medicare Advantage (MA) plan. The MA plan does have OON benefits. Must I submit a claim to the MA carrier and are there limitations in how much I can charge the patient? Answer #2 The content here is for members only log in here or sign up. Question 3 I’m not enrolled in the Medicare program and not enrolled with the Medicare Advantage (MA) plan. The MA plan does have OON benefits. Must I submit a claim to the MA carrier and are there limitations in how much I can charge the patient? Answer #3 The content here is for members only log in here or sign up. Question #4 I’m enrolled in the Medicare program as a participating provider and not enrolled with the Medicare Advantage (MA) plan. The MA plan does not have OON benefits. Must I submit a claim to the MA carrier and are there limitations in how much I can charge the patient? Answer #4 The content here is for members only log in here or sign up. Question #5 I’m enrolled in the Medicare program as a non-participating provider and not enrolled with the Medicare Advantage (MA) plan. The MA plan does not have OON benefits. Must I submit a claim to the MA carrier and are there limitations in how much I can charge the patient? Answer #5 The content here is for members only log in here or sign up. Question #6 I’m not enrolled in the Medicare program and not enrolled with the Medicare Advantage (MA) plan. The MA plan does not have OON benefits. Must I submit a claim to the MA carrier and are there limitations in how much I can charge the patient? Answer #6 The content here is for members only log in here or sign up. I hope you found this article informative and helpful. Thank you for being a Gold Member!
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Hi Rick, I am curious what you have found. I have billed several MA HMO’s for providers that ARE contracted with Medicare, but no affiliation with the MA plan. These are being paid at Medicare rates. So my assumption from some research, talking to reps, that even HMO’s can be billed IF you are contracted with Medicare. They are paying the providers. Have you come across this? Thanks!
You would need to check with each MA plan to see if they have OON benefits. Most HMO’s don’t have OON benefits.
The only way to be paid by an HMO plan is to be in network with a HMO plan.
That is correct as most do not have OON benefits.
Rick
I am a little confused by your answer to #4. If a therapist is not contracted with the MA plan and the MA plan does not have OON benefits, how does the MA plan have the obligation to pay that therapist?
The answer does not say that.