NON PAR Physicians and Limiting Charge

If a patient with a Medicare Advantage Plan sees a physician out-of-network, coverage will be determined by their health plan, and most plans do not have out of network coverage.

For the Physicians, regardless of coverage, the maximum that can be charged to a Medicare beneficiary is the Medicare fee. Even if the patient does not have coverage and the physician is not participating with the Medicare Advantage Plan.

This protection also extends to Medicare eligible, but not enrolled patients, who are covered under the Federal Employee Health Benefit Plan or their spouses. The maximum that can be charged to the patient is the Medicare limiting charge.

If the Physician is participating, or non-par, taking or not taking assignment, the maximum that can be charged is the Medicare fee. The only exception is if the physician has withdrawn from Medicare, and has the patient sign an acknowledgement.

At Medcare MSO we make sure that our clients have true projection of payments and reimbursements. If you have any question regarding your patient class and community. Call us today at 800-640-6409 and schedule an appointment with one of our billing support specialists.

Warning about EMR/EHR

Electronic Health Records (EHR) and Electronic Medical Records (EMR) often come with software to “advise” you about coding. This advisory software is promoted as increasing your revenue by advising you that if you document more, you can increase your CPT to a higher level. If you document completely, your level 3 visit can become a 4, or even a 5.

In reality, the services provided must be appropriate for the diagnosis given. Level 4 and 5 billings will readily be identified and should be expected to be challenged. Don’t assume that your automated code advisor with your electronic medical records software will have eliminated these challenges. If the diagnosis does not fit, the CPT code is declared excessive.

Somewhere in the documentation of your software is a disclaimer that explains that their code advisor is simple advising, the determination of the appropriateness of coding, and the responsibility-liability-for the actual coding remains the physicians’ responsibility. Watch the diagnosis as well.

The level of services provided must also be commensurate with the diagnosis under treatment. While all the requirements of a level of care may be fully and completed documented, does the diagnosis under treatment warrant the level of service? Increasingly payers are using computerized models to compare CPT codes with the diagnosis codes and identify patterns of what they allege to be excessive services for the diagnosis listed. For Example an ear infection in an otherwise healthy patient would be difficult to justify level 5 E/M, even if the level 5 were fully documented according to the documentation standards.

At Medcare we make sure that codes are compliant to the level of care and AMI regulations. To become a client or schedule a demonstration, please reach us at 800-640-6409.