PRACTICE PEARLS

Your patient's private, fee-for-service (PFFS) plan is a type of Medicare Advantage health benefit plan offered by a state-licensed risk-bearing entity (i.e., an insurance company) that has a yearly contract with the Centers for Medicare & Medicaid Services (CMS) to provide beneficiaries with all their Medicare benefits plus any additional benefits the company decides to provide.One major difference between a PFFS plan and other Medicare Advantage plans (e.g., Medicare HMOs) is that, in most cases, beneficiaries who join a PFFS plan are not required to use a particular network of physicians. Beneficiaries can see any physician who is eligible to receive payment from Medicare and agrees to accept the PFFS plan's standard payments.A physician must follow a PFFS plan's terms and conditions of participation if the physician knows prior to furnishing services to a patient that the patient is enrolled in a PFFS plan and the physician either possesses or has access to the plan's terms and conditions of participation. A PFFS plan is required to make its terms and conditions of participation “reasonably available” to physicians in the United States.In most instances, if a Medicare beneficiary presents his or her PFFS plan enrollment card (which will typically specify a phone number or Web address where you can obtain the PFFS plan's terms and conditions of participation) in advance of the service and you proceed to provide the service, you will be considered a “deemed” physician. This means you will be subject to the plan's terms and conditions, including its fee schedule and beneficiary cost-sharing limitations.It is important to note that you are not required to furnish health care services to enrollees of a PFFS plan. However, when you choose to and the deeming conditions have been met, you are automatically a deemed physician for that enrollee and must follow the PFFS plan's rules. Note that the physician can make the decision to be “deemed” for individual patients on a case-by-case, per-visit basis, so you can be deemed for one patient but not another, and you can be deemed for a patient at one visit but not at his or her next visit.To be paid by a PFFS plan, you must file your claim according to the plan's terms and conditions of participation. The Medicare carrier to which you submit traditional Medicare claims will not accept claims for enrollees in a PFFS plan.For more information on Medicare PFFS plans, visit the CMS Web site at http://www.cms.hhs.gov/privatefeeforserviceplans.