Same HMO—Different Benefits
An HMO is not an HMO is not an HMO. I know that sounds confusing, but you can have a Medicare HMO, a Medicaid
HMO, or an ERISA HMO. AN ERISA HMO is one provided by an employer. A Humana HMO is different than a BCBS HMO and a
BCBS HMO can become very confusing. BCBS is nationwide. It operates independently in a state, so a BCBS HMO in New
York (Empire BCBS) is different than an HMO in Florida (Health Options). Depending on the plan, you may have to
send the claim directly to the out of state plan or through your local plan. How the plan pays is usually according
to the patient's HMO contract.
There are many Medicare HMO plans out there. BCBS may have a Medicare HMO, Humana may have a Medicare HMO. Avmed
has a Medicare HMO. With each HMO, the patient has assigned benefits, certain requirements to remain in network,
and benefit requirements such as to obtain authorization. Some Medicare HMO benefits are alowed based on
For example, my mother's Medicare HMO policy is good in the county where she lives. If she visits me, her HMO
doesnt allow routine medical care for going out of network. The exception is in an emergency and then there are
requirements for that. The HMO medical director is the one who determines of the medical condition was emergent.
Most HMOs come under the jurisdiction of the State Insurance Commisioner. Medicare HMOs do not. THis is based on
many letters I have from the Florida Insurance Commisioner. Medicare HMOs come under the jurisdiction of the
regional CMS Office. For those of us in Florida, this would be the CMS office located in Atlanta.
Medicare has available the Medicare Managed Care Manual:
under normal circumstances when a Medicare HMO pays a claim, it is suppose to pay the Medicare allowable for the
geographical area where the service was rendered. Normally, the provider cannot accept a claim payment that exceeds
the medicare allowable. If you live in an area that has multiple fee schedules, you need to keep an eye on the
payment. I normally create a spreadsheet of all of my provider's CPT codes. The spreadsheet contains the code, the
charge and the Medicare alowable for that code. For example, CPT 99213 may have a charge of $200. The Medicare
allowable may be $75.00 This tells me that the medicare allowable is 30% of my providers charge. By treating a
Medicare HMO patient my doctor is taking a $125 loss. This is also important when negotigating a contract. The
non-Medicare HMO, PPO, or POS, may say all we pay is 80% of the Medicare allowable. My doctor may say he wont go
below 70% of charges or in this example, $175. If the allowable is $75, 80% of that is $60 or a loss of $190.
The patient could belong to a Medicare PPO or POS through Medicare Advantage or Medicare Part C. Claims payment
varies per PPO or POS policies established with the patient:
Medicaid HMOs usually come under the jurisdiction of the State agency that regulates Medicaid for the State.
Normally the payment for treating a Medicaid HMO is the established Medicaid allowable.
Now, comes the fun part. Can you balance bill an HMO patient? That has no cingular answer. It can depend on
State Law. If the service is not covered under the policy, then the patient could be billed. In some States, HMOs
have now developed deducibles, some reaching as high as $5,000. Some HMOs have the patient pay visit co-pays. THis
can range from $15 to $40 or more, depending on the policy. With some policies Ive seen, if the patient went to the
emergency room and it was determined, by the HMO, that the visit was NOT an emergency, then the HMO member pays all
of the charges. Some provider contracts absolutelt forbid billing the HMO member. Some require the provider to give
a discount to what is billed to the member. A Medicaid patient could be billed under certain circumstances. (1) If
the service is not allowed under medicaid or (2) if the HMO member went out of network without authorization.
With a Medicare patient, if the patient is requesting services that Medicare doesnt allow, such as a routine
physical, then the provider has a requirement to inform the patient of the possibility of denial. For example, the
patient's policy only allows 15 visits to a chiropractor. The patient saw Dr Jones for those 15 visits and wants to
try and work the system, so now the patient goes to Dr. Smith. Because the patient used up all benefits, the claims
with Dr. Smith may be denied. Or, the patient contacts a DME company to rent a shower chair, The shower chair may
not be a benefit the patient is entitled to receive. The provider or the provider's employee sits down with the
patient and explains that the service has a possibility of being denied. The patient acknowledges this with an
Advanced Beneficiary Notice (ABN Form). YOu place a copy of this document in the patient's file. You submit the
claim using modifier GA. If the claim is denied, you can pursue the patient. Just be aware the patient may become
beligerent and angry in order to get you to write off the debt. I've seen some patients say they never signed
anything, and when approached with the ABN form, they agree they signed the form, but they will change tactics to
get you to write it off.
You should know your state HMO laws. Not every state has them.
(Reprinted with permission from the
author, Steve Verno, Medical Biller)
Post Your Medical Billing Job
We are enrolled in the Indeed Publisher Program and their job
search tools are included on our site. Your job ad appears throughout the Indeed
network and on our medical billing job website for
the next 30 days.