Medicare Part C plans while legally required to provide coverage to the same services/products as FFS Medicare have a great deal of latitude as to how they provide those services. Medicare Advantage Plans can and do invoke prior authorization programs for many DME services, sometimes based on their fee schedules, which often are less than ½ of FFS Medicare.
The Medicare Advantage plans also have implemented prior authorization guidelines of medical necessity which are inconsistent with the coverage parameters of FFS Medicare. Pending legislation for 2024 aims to curtail this abuse. There also have been instances where prior authorization is granted but the claim is denied, leaving the provider often with little legal recourse for reimbursement. Lastly, the Medicare Part C Plans often provide carved out networks for DME. That is, only a very small handful of network providers are allowed into the carved-out group, leaving most network providers unable to be reimbursed for DME services. This leaves patients with long waiting times for appointments and can create huge medical issues for patients requiring acutely needed DME. By providing care in this manner, the Part C carrier can invoke its will on providers who have little recourse and who are easily be replaced by many others groveling for a place in the carve out network.
Fee schedules under many Part C carriers are only a fraction of FFS and commercial insurance plans. Thus it is very important for your practice to be extremely efficient and have a copy and absolute understanding of all the coverage policy information. Charting must follow these requirements in the same orderly fashion as the policy and prior authorization guidelines must be followed to the “end” degree.
As with FFS Medicare, one should obtain and review the coverage policies and fee schedule prior to providing any DME. Because prior authorization requirements are often very complicated, it is very important not to provide any DME to patients, prior to having all the required coverage and payment information in writing from the carrier.
