Medicare Advantage Non-par Claims

[somarco]

How often do non-par claims appear in Medicare Advantage? I see it quite often in traditional (under age 65) health insurance, especially with PARE claims.

MAPD plans typically have smaller networks vs regular health insurance so I would imagine these issues would come up on a regular basis.

 

[WCMason]

How often do non-par claims appear in Medicare Advantage? I see it quite often in traditional (under age 65) health insurance, especially with PARE claims. MAPD plans typically have smaller networks vs regular health insurance so I would imagine these issues would come up on a regular basis.

For the over 65 crowd I don't believe they exist outside of Original Medicare. If it turns out otherwise I'm also interested in finding out how.

 

[somarco]

They do exist, but it appears there is a limit on how much the provider can bill unless they have completely opted out of Medicare. That is a good thing vs U65 health insurance.



General Medicare Frequently Asked Questions (FAQs)

A non-participating provider is a health care provider who does not agree to accept assignment on all Medicare claims. If a non-participating provider does not accept assignment on a claim, he or she may charge more than Medicare's approved amount, but not more than the limiting charge. The limiting charge is 115 % of the Medicare approved amount. A non-participating provider may also collect full payment directly from the patient at the time of service. When a provider does not accept assignment on a claim, Medicare sends its payment directly to the beneficiary, not to the provider.

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Something more comprehensive from CMS

https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/downloads/oon-payments.pdf

 

[somarco]

I find it hard to believe MAPD agents have never encountered this situation with PARE claims. Happens routinely with major medical. Given the tight MAPD networks it has to come up more regularly than in the U65 market.