Avoiding the Medicare “Advantage” Traps

Avoiding the Medicare “Advantage” Traps

A patient comes to you, says I have Medicare primary and then United Healthcare. You bill in that order, but are puzzled when Medicare denies the claim with the following reason code:


Now what do I do?

You are a counselor or marriage and family therapist who cannot accept Medicare. A patient starts treatment and gives you an Aetna card. Aetna pays you – but a year later they claw back the money, stating you weren’t entitled to it because your license isn’t eligible for Medicare. But when you called to verify benefits, you were told you were in network and the patient had benefits to see you.

The patient had Aetna! What does Medicare have to do with anything?

You have several patients with BCBS and are in network. However, your claims come back paid at a different (lower) rate than usual, plus a small deduction marked “sequester.” Over time, it’s added up to hundreds of dollars. You try to figure it out and get nowhere.

No one seems able to explain it and they pass me around to different departments.

You are a Medicare provider. You’ve been seeing a patient with Medicare and a supplement for years. Suddenly, Medicare denies your claims, stating they aren’t the correct payer. You don’t understand.

How can someone have Medicare, stay retired, but then suddenly have something else for insurance?

WHY do they make this so confusing?

The one thing that all these scenarios probably have in common is that the patient may have what’s known as a “Medicare Advantage” policy.

The mental health community is often confused about what Medicare Advantage is and isn’t – so Your Billing Buddy is going to set you straight, because it often seems like no one else will.

In brief, without any technicalities, judgments, or public policy justifications/disputes for the existence of the Medicare Part C program (AKA Medicare Advantage) … these are alternative commercial plans that Medicare beneficiaries are allowed to choose. Once enrolled in Medicare Advantage, any claims to Original Medicare will deny with the above reason code that Medicare is not the correct payer.

(An exception – because there must always be one, right? – If your patient is hospice enrolled, you will go back to billing Original Medicare, with a hospice modifier).

In 2021, according to the Kaiser Family Foundation healthcare research, 42% of Medicare beneficiaries were enrolled in Medicare Advantage.

That was about 26 million people – so if you haven’t yet seen one of these common scenarios in your practice, you will. It’s only a matter of time, especially given the aging demographics of the population.

So how do I protect myself from denials, clawbacks, and fee erosion?

There are only two things you need to do to avoid the tricky trap of Medicare Advantage:

Get their Insurance Cards

After 24 years as a biller for mental health services, I’m still shocked by how many providers (and their EMR systems) do not feel it necessary to capture this information. Insurance cards have all sorts of logos on them that provide valuable information.

All Medicare Advantage cards are easily identifiable. Terms such as Medicare Advantage, A Medicare Private FFS Plan (fee for service), or [Payer name] Medicare are usually prominently displayed. Also, look out for cards marked Dual and/or SNP – these are Medicare Advantage plans for patients who are also eligible for Medicaid and combine both benefits into one policy.

Some examples (there are many)

Verify Eligibility

Read the fine print of the section that shows you the funding source of the plan.  (Although a card like the above would tell you all you need to know).

So ok, they have Medicare Advantage. Now what? Can I take this plan?

In order for you to be paid for your services, as of 2019 you must be an eligible, enrolled Original Medicare provider in order to be paid by a Medicare Advantage plan.

But: You do NOT have to participate in the network of the Medicare Advantage payer offering the benefits. If you aren’t, you will be paid 100% of the Medicare fee schedule. If you signed the CMS-460, you cannot balance bill. Non-participating providers may bill up to 115% of the Medicare allowable rate, just as they can with Original Medicare.

In fact, it may be preferable NOT to contract with Medicare Advantage plans. The Original Medicare allowed amount is typically anywhere from 10-40% MORE than you would be paid if you were a participating provider in a Medicare Advantage network.

The sequester applies to reimbursement from both Original Medicare and Medicare Advantage, so while it is not part of the reason why Medicare Advantage plans pay less, it is a clue that your patient with a commercial plan in fact has Medicare Advantage.

Caution: there are Medicare Advantage plans that do not offer out of network benefits – so you have to verify if there is out of network coverage. Medicare Advantage patients who have no out of network benefits have the same choice as any other patients with policies not featuring out of network coverage: self-pay or choose another provider.

Original Medicare providers are under no obligation to participate in Medicare Advantage plans.

Nor do they have to opt out in order to accept a Medicare Advantage patient who wishes to self-pay. Also, no ABN is required for Medicare Advantage patients.

Providers who are opted out from Original Medicare can NOT be paid by Medicare Advantage plans.

I find that the biggest trap of all with Medicare Advantage, is the fact that patients don’t always understand it. When they call for service, they give incorrect information, and busy practitioners without a lot of support tend to take patients at their word. Remember, your patient isn’t trying to deceive you – but this stuff is hard to understand, or you wouldn’t be reading this blog. So, understanding your patient’s plan type could save you hundreds if not thousands of dollars later in denied or clawed back claims.

No Surprises Act: Death by Attestation

No Surprises Act: Death by Attestation

By now, we’ve all heard more than we probably want to about the No Surprises Act and Good Faith Estimates. But there is another part to the whole Consolidated Appropriations Act puzzle that concerns mental health professionals.


What we think of as the “No Surprises Act” is not a law unto itself. No Surprises, along with several other healthcare provisions that will affect practices in the years to come, was bundled into a huge spending bill passed on December 21, 2020, titled the Consolidated Appropriations Act.

An interesting factoid, courtesy of the Senate Historical office: The CAA is the longest bill ever passed by Congress, to date. It tops out at 5,593 pages.

I wonder how many members of Congress actually read all 5,593 pages …

This blog concerns the tightening of provider directory regulations.

There are regulations for provider directories? Really?

Yep. And they aren’t new, either.

As of January 1, 2016, CMS became legally authorized to fine Medicare Advantage plans up to $25,000 per beneficiary if the number of errors in network provider directories exceeded a certain threshold. It doesn’t take a math major to realize that even 50% of this penalty would be a huge chunk of change out of a health insurer’s pockets.

The effect on practitioners began slowly, without much notice or fanfare. You’ve all been subjected to it, probably without ever realizing why (other than to moan about what an annoying pain in the rear it is). Services like CAQH, Availity, and the insurance payers themselves began sending around emails: VERIFY YOUR DIRECTORY ENTRY NOW.

Later, those same emails started to become more nagging, almost threatening, in tone: YOUR QUARTERLY ATTESTATION IS NOW DUE. ACT NOW TO AVOID DIRECTORY REMOVAL.

And. They. Just. Kept. On. Coming. From everyone.


Wait, what? They can do that?


Prior to January 1, 2022, directory suppression of providers who did not re-attest was at the discretion of the health plan. To my knowledge, most plans never suppressed names. The only plan that I have encountered which did, was United Healthcare.

At least on the national level. Some states (California, for one) did have stricter requirements prior to the Consolidated Appropriations Act.

But as of January 1, 2022, the No Surprises Act mandates:

  • Health plans must refund enrollees the additional costs for out of network care if they paid an out of network bill for services & can show they went out of network because of inaccurate plan directories. Yes … Really!
  • Health plans must pay an out of network claim with in-network level cost-sharing, if the patient saw an out of network provider due to a directory error. I would imagine that the patient would have to do some serious advocacy on their own behalf, though.
  • In this event (an out-of-date directory) the out of network provider must not bill the patient more than the in-network cost-sharing. No balance-billing.
  • Providers can require health plans to remove them from the directory at the time they terminate their contract.
  • Health plans must have a regular method of verifying provider directory information.
    • Payers must update their directory within 2 business days of receiving new information.
    • Payers must confirm with providers every 90 days to re-verify accuracy of information.
    • Payers must suppress provider information from directories if attestations aren’t received every 90 days. (Note: suppression does not affect claims for ongoing patients. Those will still be paid at the in-network rate. It’s the online directories that will not list your name. Maybe you don’t care …. But if an existing patient changes insurance, only to consult their new directory and discover that you are no longer listed…then what?)

Certainly, the need for accurate directories is important. Nor would verifying, or attesting, be a huge problem on the provider side, if a way existed for providers to go one place once per quarter and disseminate the same information to all plans. (Wasn’t that the original point of CAQH?) The burden comes with having to go multiple places online to provide the same information, take phone calls, fax or email forms. It’s a burden even for providers who have staff – because employees must be paid. This is employee time that could be devoted to patient care or billing.

Further reading, if you’re so inclined…



Getting Paid for Telehealth

Getting Paid for Telehealth

Trying to figure out how to get paid for telehealth? *

*Doing audio-only? Coding and policies for audio-only telehealth are different. This blog focuses only on two-way audio/video telehealth.

If you thought it was bad in 2021, when you just had to deal with whether to use Place of Service (POS) 02 versus 11, and modifier -GT versus -95, now there’s a new complication.

Announced by CMS on October 13, 2021, the new place of service code (POS) for telehealth is 10, and it indicates telehealth when the patient is receiving services at home. Meanwhile, POS 02 has been shifted to denote that the patient is somewhere other than at home.

Don’t ask me why they felt it was necessary to make this distinction…

Next year, there will be a place of service for the bathroom.

When announcing the new POS 10, CMS originally stated that the implementation date for Medicare was April 4, 2022. However, the renewal of the Public Health Emergency (PHE) on April 13, 2022, trumps Medicare’s implementation of POS 10, because, according to the emergency waivers issued at the start of the COVID-19 pandemic, the telehealth flexibilities put in place as of March 6, 2020, will last until the end of the PHE (currently set for July 15, 2022).

Therefore, until the declared end of the PHE, coding telehealth for Medicare is still POS 11 (or whatever POS you would have used prior to the pandemic), plus modifier -95. This also applies to Medicare Advantage and Dual (Medicare + Medicaid) commercial plans.

Note: Medicare will pay for POS 10 (and 02) during the PHE, but coding POS 02 or 10 will impose a rate reduction.

This is because according to pre-pandemic Medicare telehealth policy, telehealth was subject to fee reductions. Medicare instituted the COVID telehealth billing flexibilities so as not to have to reprogram their payment systems, and also to ensure that healthcare providers could stay in business – sort of an important consideration during a worldwide pandemic.

What about commercial payers?

That’s the problem. Unlike Medicare and other government payers for whom billing instructions are a matter of public record, private payers don’t always openly disclose what they expect regarding telehealth coding – or they do, but it is often unclear, incomplete, and/or they make it so hard to find that it takes hours of searching.

Why is this so difficult? I just want to know how I can get paid for telehealth! Why can’t they all agree on how to bill it?

If I had the answer and solution to this problem, I would be able retire to Bora Bora tomorrow and you would have to find another Billing Buddy.

It’s frustrating, but right now everything depends on the payer and the policies they have implemented with regard to billing for telehealth. Some payers simply follow the lead of CMS. Others do their own thing…and they aren’t always consistent about it, either.

Your Billing Buddy’s recommendations for commercial payers:

  • Check the payer’s website to see what (if any) instructions exist regarding billing for telehealth. I typically start by looking at the links marked “COVID-19” and then clicking around randomly until I get to information about telehealth and, hopefully, information about how to bill it.
  • If you DO find something definitive, print it out. This will give you a snapshot of the date you obtained the information. Save it – you never know when you might need it in case of a clawback / recoupment attempt.
  • Maintain a log or spreadsheet of the telehealth billing policy / coding requirements of the payers you bill most often.
  • If you have time, feel free to call the payer, just don’t be surprised if it takes you a long time on the phone and at the end of the call you are more frustrated (but no more enlightened) than you were an hour or two previously.
  • Subscribe to payer newsletters, blogs, and watch for webinars and trainings they offer.
  • When in doubt, stick with POS 02 as long as the PHE remains in effect.
  • If am unsure whether POS 10 is acceptable yet, but think it appropriate to try, I send in one test claim. I make note on my spreadsheet of the patient account #, date of service, and date submitted. Then, before submitting any more, I wait until it is adjudicated. Once I have my answer, I correct and release the remainder of claims that I have put on hold. That way, if the claim does get denied or underpaid, a single claim can be corrected quietly, without a large number of claims needing correction.

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