Not Contracted With Medicare Advantage? CMS Ends Dispute Resolution

After Jan. 31, 2014, the Centers for Medicare & Medicaid Services (CMS) no longer will offer the services of an independent contractor, C2C Solutions, Inc., to adjudicate payment disputes between noncontracted physicians, and Medicare Advantage organizations and other payers. CMS says this is due to budgetary constraints.

C2C will continue to adjudicate all payment disputes received by Jan. 31 that meet the filing requirements. After Jan. 31, C2C will return any payment disputes with instructions to contact the Medicare Advantage organization or other payer directly to dispute the payment.

Other payers affected are Program of All-Inclusive Care for the Elderly (PACE) organizations, Section 1876 cost plans, and health care prepayment plans. If you have exhausted a plan's internal dispute process but still maintain you have not been paid fairly, you may file a complaint by calling (800) Medicare in addition to taking other action you deem appropriate. (CMS does not offer advice about your potential rights in a payment dispute.)

While you should continue to meet any applicable deadlines in appeals you are pursuing, TMA members also can turn to the TMA Hassle Factor Log to help resolve insurance-related problems, including Medicare problems. In 2102, the Hassle Factor Log recovered $26.2 million for TMA members from incorrectly processed claims, lost or delayed Medicare enrollment applications, and other problem claims. 

Medicare Advantage organizations and the other payers must  follow regulations at 42 CFR §§422.214, 417.559 and 422.520 when paying noncontracted providers for services provided to Medicare beneficiaries. Noncontracted providers are required to accept as payment, in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare. 

Published Jan. 21, 2014

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May 13, 2016