Wednesday, May 25, 2022

Re: Medicare Advantage plans

Jim Chea


In the
current state of Medicare audits and prepayment audits, I was wondering if
anyone is encouraging Medicare patients to switch to Medicare Advantage plans.
Has anyone experience audits from any Medicare Advantage plans? Can plans that require
prior authorization audit after payment or has anyone experienced this? I’m
interested in hearing what others are doing.

of Answers:

replies appear to be against switching patients to Medicare Advantage
plans. Medicare Advantage plans appear
to be auditing, requiring prior authorizations, not having prosthetic coverage,
being out of network, etc. There were a
couple of replies that reported they have not been audited by Medicare Advantage
plans as of yet.


have had two post-payment audits by Blue Cross Blue Shield (which had

-I would advise them carefully. We have had a patient who
ended up on a plan with no prosthetic coverage. Also, contracts with the
advantage plans are separate and your area may be blacked out to new providers
and therefore you are out of network.

Medicare advantage plans now have the same rights as CMS when it comes to
audits.Personally I think the advantage plans sole
purpose is to lower the overall cost of medical care privately.

-Jim, we in NH
have not had any Medicare Advantage Plan audits.

-There is no
advantage with advantage plans when it comes to MC. UHC is preauthorizing all prosthetics using
MC guidelines; which is good, but others are not and doing audits later and
recouping money the same.

-I have not heard of any audits from the
Advantage plans and I most certainly encourage not only patients, but friends
as well to search these plans out.
Another suggestion I have is for O&P billing personnel,
practitioners and/or owners to contact their US Senators in regards to a law
that is and has been on the books for some times; Advance Benefit Determination
(see attached). This would be so much better
than prior auth as it is voluntary. I
have contacted CMS as well as Senator Susan Collins who is currently working on
this. This law was put in place for a
reason but to date, the only items that we can submit an advanced determination
request is for power mobility devices.

-I’ve not had an audit from any Medicare Advantage plan.

yes. Any M. Care replacement plans are subject to audits. Humana has been the
most aggressive with auditing replacement plans.

-We are doing the opposite. Those with
advantage plans are not paying, denying, or limiting access.

-Yes, we have received audits on 3
patients with Medicare advantage plans.
Medicare audits them and they have to scramble to get the paperwork from
us. In one case we were required to
provide the documentation in <24 hours. I do not believe any of the audited claims required prior authorization, but I'm sure that wouldn't stop Medicare from auditing the claim. -We've had good success with Care Improvement, although it has to be pre-authorized. At least you know if it was pre-authorized you get to keep the money if they pay. Humana is about the same, harder to get pre-authorized and they pay less. There was a post today on the list serve about Region A going to a pre-authorization for there is some hope for O&P. -i have thought of this but my main problem is that i dont have contracts with all of them is there a way around getting a contract with say humana vs the medicare advantage plan? Cheers, Jim Chea, CPO Evergreen Prosthetics and Orthotics


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