Medicare Advantage Plans & Outpatient Therapy Services

With approximately 15 million Medicare beneficiaries enrolled in Medicare Advantage plans under Medicare Part C, I am often asked if the Medicare Advantage plans follow the same rules as traditional Medicare for outpatient therapy services in terms of Functional Limitation Reporting, the application of the Multiple Procedure Payment Reduction policy, PQRS for private practices, CCI edits and the use of modifier-59, using the therapy specific modifiers (i.e. GN, GO, GP), and the application of the Medicare therapy cap, just to name a few. While Medicare Advantage plans must follow certain federal guidelines, they are offered by private insurance carriers such as Aetna, Blue Cross, Cigna, and UnitedHealthcare. Therefore, providers accepting Medicare Advantage patients must follow the terms and payment conditions of the specific Medicare Advantage plan and also meet the federal Medicare requirements that apply to the Medicare Advantage plans.

So back to our original questions. Do Medicare Advantage plans require Functional Limitation Reporting? Do they apply the Multiple Procedure Payment Reduction policy? Do they require private practices to report the PQRS measures? Do they use the CCI edits and the use of modifier-59? Do they require the use of the therapy specific modifiers (i.e. GN, GO, GP) on each service billed? If I am not enrolled in a Medicare Advantage plan, can the Medicare Advantage beneficiary pay out of pocket and would I need to use an Advance Beneficiary Notice? And lastly, are they mandated to follow the therapy cap policy?

Lets talk about the Medicare therapy cap policy first. Medicare Advantage plans are