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 The only exception is if the physician has withdrawn from Medicare, and has the patient sign an acknowledgement.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.