Frequently Asked Questions - Pricing & Reimbursement
All FAQs are current as of the date noted next to the question.
| 1. | What does PFFS mean? |
The Balanced Budget Act of 1997 allowed for a new type of Medicare Advantage (MA) plan, Private Fee For Service (PFFS). A MA PFFS plan may be designed without a provider network. In order to offer a PFFS plan without provider contracts, the PFFS organization must agree to pay all Medicare eligible providers the current Medicare allowable rates (including original Medicare deductibles and coinsurance) minus any plan specific enrollee cost sharing. This payment rate is mandated via specific regulation as well as the contract that the CMS holds with the PFFS organization. Further, depending on the PFFS plan design, providers may balance bill enrollees of PFFS plans. However, even if the plan design allows this balance billing, it is limited to an amount of 15 percent of the PFFS plan payment amount.
The Centers for Medicare & Medicaid Services (CMS) offers a helpful Web page to answer any questions you may have at http://www.cms.hhs.gov/PrivateFeeforServicePlans/ A document that defines a variety of acronym's can be found on the WPS Medicare Website by clicking here. Date Posted (06/20/06) |
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| 2. | Why was my claim paid at a lower allowed amount for surgery than what is shown on the Medicare fee schedule? |
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With the procedures you are billing, Medicare bases reimbursement for the paid amount upon multiple surgery guidelines. To find out more specifics about multiple surgeries, please refer to National Coverage Provision (NCP) GSURG-001 on the Medicare Website by clicking here.
In addition, we frequently publish articles in our monthly newsletter, the Communiqué, which address this topic. Finally, the Medicare Physician Fee Schedule Database (MPFSDB) contains indicators which point to whether or not a given procedure code is subject to multiple surgery guidelines. When this applies, Medicare reduces reimbursement for second (and additional) procedures. You may find the MPFSDB by selecting this link. Date Posted (06/04/07) |
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| 3. | I understand that Medicare takes the deductible and coinsurance amounts into consideration when determining the reasonable charge for a service or item. When a patient is not able to pay his/her annual deductible or coinsurance, how can I determine when it is okay to write-off the charges, without violating the law that pertains to kickbacks and false claims? What can I do to verify financial hardship? |
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It is important that providers not write-off coinsurance and/or deductibles until the provider establishes the financial hardship of the beneficiary. Providers must make a reasonable effort to collect payment from the beneficiary. A reasonable effort would entail the issuance of a bill to the beneficiary or responsible party. The provider should also follow-up with subsequent billing, collection letters, and telephone calls. A genuine effort to collect payment is necessary before writing off these charges. Providers should never routinely write off deductible and coinsurance charges.
The Centers for Medicare & Medicaid Services (CMS) addresses this issue in the Internet-Only Manual (IOM), Publication 100-4, Chapter 23, Section 80.8.1. To view a copy of this publication, please refer to the CMS Website below: http://www.cms.hhs.gov/manuals/downloads/clm104c23.pdf Date Posted (07/16/07) |
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Page Last Updated: Tuesday, 04-Dec-2007 13:19:00 CST
