Medicare Advantage and Out of Network Rates

 tagmedicareadvantage, tagoutofnetowork

Labs Often Get Paid CMS Rate for Out of Network Lab Claims

Why?

###

Rule 422.214 on Out of Network M.A. Payments

Where this comes from is 42 CFR 422.214.   This rule does not directly state that Medicare Advantage must pay the FFS rate to non contracted (out of network ) providers.  However, it says that out of network providers must accept the FFS rate.   That is, the provider can appeal any rate paid that is less that the FFS rate.   Also, there is a clause that when an out of network provider submits a claim to Med Adv, it is "deemed" to be for the Medicare FFS payment rate. (422.214(c).)

https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-E/section-422.214

####

There is also a Medicare Advantage policy manual (Internet only manual 16) with about 20 chapters on different aspects of Medicare Advantage.  Chatper 4 section 100 manualizes a reference to 422.214.

https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/mc86c06.pdf   see section 100 for reference to 422.214.

It's cited to SSA 1852(a)(2) and to 1852(k)(1), and to a preamble that appeared June 29, 2000.   The June 29, 2000, rulemaking is presented at 65 FR 40325 (and alter amended; see 422.214 webpage, bottom).

https://www.federalregister.gov/documents/2000/06/29/00-15648/medicare-program-medicarechoice-program#page-40325

Discusson at:

https://www.federalregister.gov/d/00-15648/p-1066

The preamable text which helps interpret the intenton of the regulations, is here:

Special Rules for Services Furnished by Noncontract Providers (§ 422.214) 

Consistent with sections 1852(k)(1) and 1866(a)(1)(O) of the Act, § 422.214 requires that any health care provider that does not have in effect a contract establishing payment amounts for services furnished to a beneficiary enrolled in an M+C coordinated care plan must accept, as payment in full, the amounts that they could collect if the beneficiary were enrolled in original Medicare (less the amounts specified in §§ 412.105(g) and 413.86(d) of the regulations on hospital graduate medical education payments, when applicable). Any statutory provisions (including penalty provisions) that apply to payment for services furnished to a beneficiary not enrolled in an M+C plan also apply to the payment described in § 422.214(a)(1) of our regulations. We received three comments regarding this section. 

Comment:

Several commenters suggested that we revise § 422.214 to provide that payment to a noncontracting provider must equal the amount that provider would be allowed to collect under original Medicare. These commenters believe that M+C organizations should only be permitted to pay the billed amount when this is the same amount that Medicare would pay under original Medicare. 

Response:

Section 422.214 implements section 1866(a)(1)(O) of the Act, with respect to services furnished by a “provider of services” as defined in section 1861(u), and section 1852(k)(1), with respect to other services. Neither of these provisions requires an M+C organization to pay a provider more than the amount of the provider's bill, or even impose obligations on M+C organizations at all. Rather, these provisions serve as a limit on the amount the provider can collect from the M+C organization. Specifically, each of these provisions states that a provider “shall accept as payment in full” the amount (less the amounts specified in §§ 412.105(g) and 413.86(d) of the regulations) that it would receive under original Medicare, including cost sharing and permitted balance billing (“the Medicare payment amount”). While this means that under these provisions the provider cannot collect 

more than the Medicare payment amount if its billed amount is 

higher, this obligation to “accept” the Medicare amount as payment in full does not obligate the M+C organization to pay this amount if the provider's bill is 

lower. Thus, in the case of emergency services and certain other services referred to in section 1852(d)(1)(C) of the Act furnished to an enrollee in a coordinated care plan, the provider or providers must accept the Medicare payment amount for the services if their billed amount is higher, but would have no right under sections 1852(k)(1) or 1866(a)(1)(O) to be paid more than the amount of their bill if the billed amount is lower than the Medicare payment amount. 

We note, however, that a provision in the BBA does give providers furnishing services to coordinated care plan enrollees the right to be paid the Medicare payment amount under certain circumstances. Section 1852(a)(2) provides that where an M+C organization chooses to furnish services through providers that do not have contracts with the organization in order to meet its obligation under section 1852(a)(1) to make Medicare services available, it must provide for payment “equal to at 

least

” the Medicare payment amount. (Emphasis added.) This new provision, unlike section 1866(a)(1)(O) or section 1852(k)(1), establishes a “floor” for payment when it applies. This “floor,” combined with the “ceilings” under sections 1866(a)(1)(O) and 1852(k)(1), essentially requires that the Medicare payment amount be paid where section 1852(a)(2) applies. Because section 1852(a)(2) refers to an M+C organization's furnishing services in fulfillment of its obligations under section 1852(a)(1), we are interpreting section 1852(a)(2), in the coordinated care plan context, as providing M+C organizations with the opportunity to arrange to provide nonemergency services through noncontracting providers. Under this interpretation, the “minimum payment” requirement in section 1852(a)(2) would only apply where the M+C organization has arranged for the services in question to be provided by a noncontracting provider...