Tag: Medicare Advantage

Out-of-network payments in Medicare Advantage

The complexity of Medicare Advantage (MA) physician networks has been well-documented, but the payment regulations that underlie these plans remain opaque, even to experts. If an MA plan enrollee sees an out-of-network doctor, how much should she expect to pay?


Upcoding Part One: What is it and how common is it?

Specifically, providers and payers can sometimes hide behind that complexity to intentionally bill erroneously. Upcoding is one potentially fraudulent form of billing. Upcoding occurs when more intensive and expensive diagnoses or treatments are documented than what was actually provided to the patient or medically necessary.



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