What is a Deemed Provider in a Medicare Replacement Plan?
Once you obtain a copy of the patient’s Medicare Advantage card there are two things you need to give attention to when verifying coverage:
- Is the Medicare Advantage Plan a Private Fee for Service (PFFS) plan? Usually listed on the front of the card. If not, ask when you verify.
- Are you considered as an out of network provider with that plan?
PFFS stands for Private Fee for Service. If you treat these patients and submit bills for their services, you are considered a “deemed provider” and automatically become part of the network while treating that patient. That makes you subject to all fee restrictions and appeals processes associated with this plan.
How Does This Work?
When a patient in a private fee for service (PFFS) plan (offered by a Medicare Advantage (MA) Organization) obtains services from a provider, that provider is classified into one of three mutually exclusive categories at the time the services are rendered. The categories are:
- Direct-Contracting Provider – the provider has a direct/signed contract with the MA Organization
- Non-Contracting Provider - The provider does not have a direct contract and is not deemed
- Deemed-Contracting Provider (all four criteria listed below are met):
- The provider is aware in advance s/he will be providing services to a patient who is a member of a Private Fee-For-Service (PFFS) plan
- The provider has reasonable access to the plan's terms and conditions for payment
- The provider furnishes covered services to the enrolled member
- The provider agrees to submit the bill for Covered Services directly to the payer
NOTE: A provider automatically becomes a deemed provider for the rendered service if they meet the four criteria listed above.
Aware in Advance
A provider is "aware in advance" if notice of enrollment for this patient was obtained from:
- The Enrollee (e.g., patient presented an enrollment card)
- Center for Medicare Services (CMS)
- A Medicare Intermediary
- A Carrier
- The MA Organization
A provider is considered to have "reasonable access" to the plan's terms and conditions of payment if the plan makes its terms and conditions of payment accessible through:
- The Plan’s Website
It is then the provider's responsibility to call or fax the PFFS plan or to visit the PFFS website to obtain the plan's specific conditions for participation. Reasonable Access has not been provided if the communication was via:
- Announcements in the Newspaper
- Journal Entries
Example of Deemed Contracting
An enrollee visits the office for the first time, advises the physician that s/he is a member of a PFFS plan and presents the appropriate enrollment card. Since the provider had the opportunity to call the phone number on the enrollee card, the provider is considered deemed contracting as soon as s/he provides services, even if the provider did not actually check the terms and conditions of payments.
To Deem or Not to Deem
Do you want to avoid becoming a deemed contracting provider? It is important to note that PFFS providers can choose to participate on a service-by-service basis. So once deemed not always deemed. This means that patients are not guaranteed that a provider who saw them previously for a particular service will agree to see them for the same service in the future.
We encourage you to consult the payer’s website for specific direction on how to avoid deeming. Listed below is an example of language found in a payer’s provider toolkit. You will find that most major payers have similar language.
Providers can choose to accept PFFS patients, on an enrollee-by-enrollee basis, and even on a service-by-service basis.
Some Medicare PFFS plans allow “balance billing,” which lets providers charge up to 15% over what the plan pays for a covered service. This is why verification of benefits is so important as well as consulting the PFFS benefit information. Don’t leave $ on the table.
Compared to other MA plans, PFFS plans operate under a different set of rules and requirements. When an enrollee visits your clinic, it is up to your billing staff to educate themselves on the plan's terms and conditions of payment, which in many cases may be different than those under traditional Medicare. ALL of this research and verification must be done prior to rendering treatment to the patient. REMEMBER, the terms and conditions may include different documentation requirements and/ or cost sharing requirements.
Wait there is more! Have you met all the FDR requirements in regards to providing services and billing Medicare Advantage Plans? Not sure what that is, check out "Your Compliance Plan and FDR".