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
The content here is for members only log in here or sign up.
All material posted on our website is the intellectual property of Gawenda Seminars & Consulting, Inc. and can’t be used, reproduced, or posted as your own material without the prior written approval of Gawenda Seminars & Consulting, Inc.
This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.
Hello, “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.” Does the latter indicate the same use of the 8 minute rule as a federal medicare requirement for advantage?. Thank you
Here is another article I wrote earlier this year on Medicare Advantage plans. The “8-minute rule” is for traditional Medicare. Whether Medicare Advantage plans follow the “8-minute rule” is what you would have to check with each plan.