The second half of the Medicare and Cash-Pay PT eBook is a 20+ page Q&A section where I answer all the most common (and obscure) questions I receive on this topic…
As a little teaser for the book, and because I love my audience, today I’m giving the answer to the most frequently asked question I receive on Medicare ADVANTAGE plans:
Since patients with Medicare ADVANTAGE Plans (Part C) have signed their benefits over to a private insurer, can we see them on a private-pay basis as if they were like our Non-Medicare patients?
This is another one of those areas where the answer can change based on a number of different factors. I know of some practice owners who are adamant that beneficiaries with Medicare Advantage plans can be treated and viewed as patients with private insurance. They say they have been doing so and collecting private payment for years without any issues.
The ultimate answer to the above question is that it really depends on the individual Medicare Advantage Plan of that given patient. There are a wide variety of plans and their rules surrounding this topic may vary from one to the next. There are coordinated care options such as HMOs or PPOs, private fee-for-service (PFFS) plans, and medical savings account (MSA) plans. The most common form of Medicare Advantage plan is the HMO.
Apparently there are a number of Medicare Advantage plans in which coverage is limited only to in-network providers. In some of these situations, if the beneficiary decides to go out-of-network for physical therapy services (regardless of whether or not they are normally “covered services” in Medicare), he would be “on his own” for payment, and the out-of-network provider could accept self-payment from that beneficiary. Hooray! However, I must emphasize that this can change on a case-by-case basis, so the take-home point is this:
If a beneficiary with a Medicare Advantage plan wants to see you on a cash-pay basis and you are out-of-network with that plan, you need to call the plan and ask them if it is okay for you to provide the patient with covered services and that the beneficiary pay you directly out-of-pocket. As always, document with whom you spoke and exactly what was said.
For more general info on Medicare Advantage plans go to http://www.apta.org/Payment/Medicare/Advantage/
Also, do an Internet search for the May 2014 issue of PT in Motion magazine. You can download it if you’re an APTA member, and that issue has a good article on Advantage plans.
Click here if you want the entire story and regulations on Medicare and Cash-Based PT services. And keep in mind that this book is not focused solely on the rules as they apply to completely cash-based practices. It is written for any practice owner wondering when he/she can accept private payment for the variety of services a PT business may provide to beneficiaries.