Medicare Advantage (MA) programs represent some real challenges for healthcare providers such as physicians, hospitals, skilled nursing, home health among others. In some cases, a given provider will be part of a network or under contract to the given MA plan, and, thus, coding, billing and reimbursement are governed by the contract. In other cases, a given healthcare provider may by filing a claim with an MA plan across the country in which there is no relationship between the MA plan and the provider.

For MA programs, emphasis is given to provider relationships particularly for physicians and hospitals. If a claim is filed by a healthcare provider that is not part of the MA plan’s network, then the claim is to be adjudicated under the traditional Medicare rules. Given the variability in coverage and medical policies, there can be confusion when claims are adjudicated and paid.