Why Some Doctors Accept Medicare But Won't Accept UHC Medicare Advantage PPO

[gooch]

I have a Medicare Advantage PPO plan from United Health Care which is paid for by my employer as part of my retirement pension plan. My understanding from the literature provided by UHC is that their PPO plan pays the same as the regular Medicare Approved rate. I then pay a 20% co-payment, the same as with regular Medicare. This applies to any doctor who is In Network or Out of Network with United Healthcare.

I have been to several doctors who are perfectly willing to accept regular Medicare but they won't accept UHC PPO. Since the doctor gets paid exactly the same amount using either regular Medicare or the UHC PPO, I don't understand why they won't accept UHC PPO. Does anyone have an explanation of this situation?

 

[Mack]

Hi Gooch, and welcome to MyMedicareForum.com!

With Medicare Advantage you have to use a doctor that is in the Network as defined by the Medicare Advantage provider. Regular Medicare doesn't require you to use a doctor in any network, just use a doctor that accepts Medicare.

So I am thinking that the doctors that refused to accept your Medicare Advantage plan were not in the Network of your plan. If they are in the Network then you have a legitimate gripe. Complain to UNC. If they are not in the Network, I don't see how you have a complaint, you must use a doctor in the Network in order to be covered.

 

[gooch]

I believe you are correct for a regular Medicare Advantage but that is not true for a Medicare Advantage PPO which is what I have. The PPO will pay the same rate as Medicare pays whether the doctor is In Network or Out of Network. The doctors I am discussing are Out of Network and I know they have a perfect right to refuse me. I just question why. If they get paid the same from Medicare as from UHC, why do they care?

 

[Mack]

I think they care because they do not get enough from Medicare to begin with so since they can rightfully refuse an out of network patient they use that time to see other non-Medicare patients where they get paid more. In time they might even refuse all Medicare patients, which is their right also.

 

[gooch]

I think they care because they do not get enough from Medicare to begin with so since they can rightfully refuse an out of network patient they use that time to see other non-Medicare patients where they get paid more. In time they might even refuse all Medicare patients, which is their right also.

 

[gooch]

The doctors I refer to all accept Medicare Assignment according to their Provider listing on Medicare.gov. The doctors have all told me that if I switched to Regular Medicare, they would process my claim to Medicare. However as long as I was on the UNC PPO plan, they would not process my claim even though UNC is acting as a MAC (Medicare Administrative Contractor). The doctor's position is that since they are out of network from UNC, they don't have to process my claim. My position is that if they accept Medicare Assignment, they are required to submit a claim to Medicare as a part of the agreement that they "Accept Medicare Assignment" even if they have to send the bill to a MAC.

 

[MBSC]

Gooch asked: "I have been to several doctors who are perfectly willing to accept regular Medicare but they won't accept UHC PPO. Since the doctor gets paid exactly the same amount using either regular Medicare or the UHC PPO, I don't understand why they won't accept UHC PPO. Does anyone have an explanation of this situation?"

Medicare reimbursement rates are low compared to "under age 65" plans. Providers accept Original Medicare patients and the payment rates because of the high volume of patients. There is no incentive to see a few Medicare Advantage (MA) patients when those slots can be filled with under 65 patients whose insurance pays more.

Gooch asked: "The PPO will pay the same rate as Medicare pays whether the doctor is In Network or Out of Network. The doctors I am discussing are Out of Network and I know they have a perfect right to refuse me. I just question why. If they get paid the same from Medicare as from UHC, why do they care?"

The UHC literature is either inaccurate or you are interpreting it incorrectly. Unless the provider is a specialist in high demand, UHC PPO in-network reimbursement is generally slightly lower than Original Medicare's low reimbursement rates. There are no regulations for MA in-network reimbursement. Federal regulations only require MA PPO out-of-network providers to be reimbursed the same amount as Original Medicare when they choose to accept the patient. Again, the provider receives higher reimbursement from under age 65 patients.

MA plans have a higher tendancy to deny claims until medical notes explaining the reason for treatment are received. This creates more administrative work for the provider's staff.

Gooch wrote: "The doctors I refer to all accept Medicare Assignment according to their Provider listing on Medicare.gov. The doctors have all told me that if I switched to Regular Medicare, they would process my claim to Medicare. However as long as I was on the UNC PPO plan, they would not process my claim even though UNC is acting as a MAC (Medicare Administrative Contractor). The doctor's position is that since they are out of network from UNC, they don't have to process my claim. My position is that if they accept Medicare Assignment, they are required to submit a claim to Medicare as a part of the agreement that they "Accept Medicare Assignment" even if they have to send the bill to a MAC."

By enrolling in an MA plan, you have cut all ties to Original Medicare's claim assignment rights and claim processing rules. If a provider submitted your claim to Original Medicare, the MAC would reject it as "not enrolled" regardless of assignment since you are not on Original Medicare. MA plans are private plans and not a contracted MAC and members follow the MA plan's rules while enrolled. The out-of-network provider could see you and could submit the claim to UHC but they have no incentive to do so since under age 65 patients generate more revenue with less administrative headaches.

 

[gooch]

Gooch asked: "I have been to several doctors who are perfectly willing to accept regular Medicare but they won't accept UHC PPO. Since the doctor gets paid exactly the same amount using either regular Medicare or the UHC PPO, I don't understand why they won't accept UHC PPO. Does anyone have an explanation of this situation?"

Medicare reimbursement rates are low compared to "under age 65" plans. Providers accept Original Medicare patients and the payment rates because of the high volume of patients. There is no incentive to see a few Medicare Advantage (MA) patients when those slots can be filled with under 65 patients whose insurance pays more.

Gooch asked: "The PPO will pay the same rate as Medicare pays whether the doctor is In Network or Out of Network. The doctors I am discussing are Out of Network and I know they have a perfect right to refuse me. I just question why. If they get paid the same from Medicare as from UHC, why do they care?"

The UHC literature is either inaccurate or you are interpreting it incorrectly. Unless the provider is a specialist in high demand, UHC PPO in-network reimbursement is generally slightly lower than Original Medicare's low reimbursement rates. There are no regulations for MA in-network reimbursement. Federal regulations only require MA PPO out-of-network providers to be reimbursed the same amount as Original Medicare when they choose to accept the patient. Again, the provider receives higher reimbursement from under age 65 patients.

MA plans have a higher tendancy to deny claims until medical notes explaining the reason for treatment are received. This creates more administrative work for the provider's staff.

Gooch wrote: "The doctors I refer to all accept Medicare Assignment according to their Provider listing on Medicare.gov. The doctors have all told me that if I switched to Regular Medicare, they would process my claim to Medicare. However as long as I was on the UNC PPO plan, they would not process my claim even though UHC is acting as a MAC (Medicare Administrative Contractor). The doctor's position is that since they are out of network from UHC, they don't have to process my claim. My position is that if they accept Medicare Assignment, they are required to submit a claim to Medicare as a part of the agreement that they "Accept Medicare Assignment" even if they have to send the bill to a MAC."

By enrolling in an MA plan, you have cut all ties to Original Medicare's claim assignment rights and claim processing rules. If a provider submitted your claim to Original Medicare, the MAC would reject it as "not enrolled" regardless of assignment since you are not on Original Medicare. MA plans are private plans and not a contracted MAC and members follow the MA plan's rules while enrolled. The out-of-network provider could see you and could submit the claim to UHC but they have no incentive to do so since under age 65 patients generate more revenue with less administrative headaches.

These doctors are happy to see me and charge me the Medicare Approved Rate for the service they provide because they list on Medicare.gov that they "Accept Medicare Assignment". I pay the Medicare Assignment Rate for the service and the doctor gives me a statement showing what the service was and the appropriate code and the amount I paid. I submit the statement to UHC and they reimburse me for that amount I paid less the co-pay. It takes about six weeks to process the claim. This relieves the doctors in having to submit a claim so it saves them work and they get paid right away. The bottom line is that they get the same amount of money but don't have to deal with UHC.

 

[MBSC]

I am glad to hear the providers see you and hope that continues.

For clarification, the Code of Federal Regulations (CFR) mandates all MA PPO out-of-network providers (non-contracted providers) accept the Medicare approved rate when they see an MA member. MA members do not need to research to see if the provider accepts Medicare assignment. We apply the rule to all providers to create consistency for MA PPO plan members.

Reference: https://www.cms.gov/Medicare/Health-Plans/HealthPlansGenInfo/providerpaymentdisputeresolution.html

"Medicare Advantage organizations are required under sections 1852(k) and 1894(b)(3) of the Social Security Act and CMS regulations at 42 CFR §§422.214, 417.558 and 422.520, to reimburse non-contracted providers for services provided to Medicare beneficiaries no less than the amount that would be paid under original Medicare. Non-contracted providers are required to accept as payment, in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare. Plans should refer to the MA Payment Guide for Out of Network Payments in situations where they are required to pay at least the Medicare rate to out of network providers."

 

[gooch]

I am glad to hear the providers see you and hope that continues.

For clarification, the Code of Federal Regulations (CFR) mandates all MA PPO out-of-network providers (non-contracted providers) accept the Medicare approved rate when they see an MA member. MA members do not need to research to see if the provider accepts Medicare assignment. We apply the rule to all providers to create consistency for MA PPO plan members.

Reference: https://www.cms.gov/Medicare/Health-Plans/HealthPlansGenInfo/providerpaymentdisputeresolution.html

"Medicare Advantage organizations are required under sections 1852(k) and 1894(b)(3) of the Social Security Act and CMS regulations at 42 CFR §§422.214, 417.558 and 422.520, to reimburse non-contracted providers for services provided to Medicare beneficiaries no less than the amount that would be paid under original Medicare. Non-contracted providers are required to accept as payment, in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare. Plans should refer to the MA Payment Guide for Out of Network Payments in situations where they are required to pay at least the Medicare rate to out of network providers."

Just to tie up some loose ends: In my latest experience with a doctor, the receptionist told me that because the doctor was not in the UHC network, they would no longer accept UHC and that I would have to send the statement to UHC for reimbursement. When I checked with the Practice Manager, she told me that receptionist did not provide the correct information as it only applied to the UHC HMO plan. The PM said they would continue to submit my claim to UHC because I was on the PPO plan so nothing has changed.