Medicare Advantage and Price-Based Appeals

Generally, Medicare Advantage plans to not have to following CMS pricing and coding or bundling rules.  For example, they can have different copays on certain services, compared to fee for service Medicare.  Sometimes a rule intervenes; for example, the Trump administration in 2018 allowed Medicare Advantage plans to use step therapy rules in Part B drugs, a particular named payment policy that had been blocked during the Obama administration in 2012.   Here, here.   

What about payment level?  CMS lets MA plans offer lower payment levels, but there's a secret weapon available to the MA out-of-network provider who feels underpaid.  They can appeal the MA price appeal up to the Original Medicare rate.  I'm told this is usually successful.  It's found at 42 CFR 422.214.  Also, if the patient is outside an area where his MA plan offers in-network rates, then the MA plan "must pay on contract provider the Original Medicare payment rate."  If the MA plan is "providing access to services by non-network means."   

https://www.govinfo.gov/content/pkg/CFR-2011-title42-vol3/xml/CFR-2011-title42-vol3-sec422-214.xml

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See a 4/2022 article on Medicare and drug pricing (mentioning step therapy) here.

See my 2021 note on this MA price topic, https://brucedocumentblog.blogspot.com/2021/05/regulaton-about-medicare-advantage.html

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§ 422.214Special rules for services furnished by noncontract providers.

(a) Services furnished by non-section 1861(u) providers. 

(1) Any provider (other than a provider of services as defined in section 1861(u) of the Act) that does not have in effect a contract establishing payment amounts for services furnished to a beneficiary enrolled in an MA coordinated care plan, an MSA plan, or an MA private fee-for-service plan must accept, as payment in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare.

(2) Any statutory provisions (including penalty provisions) that apply to payment for services furnished to a beneficiary not enrolled in an MA plan also apply to the payment described in paragraph (a)(1) of this section.

(b) Services furnished by section 1861(u) providers of service. Any provider of services as defined in section 1861(u) of the Act that does not have in effect a contract establishing payment amounts for services furnished to a beneficiary enrolled in an MA coordinated care plan, an MSA plan, or an MA private fee-for-service plan must accept, as payment in full, the amounts (less any payments under §§ 412.105(g) and 413.76 of this chapter) that it could collect if the beneficiary were enrolled in original Medicare. (Section 412.105(g) concerns indirect medical education payment to hospitals for managed care enrollees. Section 413.76 concerns calculating payment for direct medical education costs.)

(c) Deemed request for Medicare payment rate. A noncontract section 1861(u) of the Act provider of services that furnishes services to MA enrollees and submits the same information that it would submit for payment under Original Medicare is deemed to be seeking to be paid the amount it would be paid under Original Medicare unless the provider expressly notifies the MA organization in writing that it is billing an amount less than such amount.

(d) Regional PPO payments in non-network areas. An MA Regional PPO must pay non-contract providers the Original Medicare payment rate in those portions of its service area where it is providing access to services by non-network means under § 422.111(b)(3)(ii) of this part.

[63 FR 35085, June 26, 1998, as amended at 65 FR 40325, June 29, 2000; 70 FR 4724, Jan. 28, 2005; 70 FR 47490, Aug. 12, 2005; 76 FR 21564, Apr. 15, 2011]