Original Medicare vs. Medicare Advantage
Understand why a Medicare-covered service and an incremental payment opportunity are not always the same question.
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Talk with us INSURANCE & CONTRACTS
Which insurance pays—and what must you verify?
Choose the coverage route below. Benefits, separate payment and contracted amounts are three different questions.
START WITH THE RIGHT QUESTION
Five payer lenses every practice should use.
No page can confirm payment for an individual patient. These guides help you identify what needs to be checked with current payer policy, contracts, professional coding guidance, and your own compliance team.
Medi-Cal and Medi-Medi planning
Use a member-, plan-, county-, and contract-level review before presenting a remote-care model in California.
Open guideFQHC and RHC considerations
Account for the distinct payment and reporting environment before applying a physician-fee-schedule assumption.
Open guidePatient cost share and consent
Make the patient’s responsibility, consent, communication preferences, and enrollment choice part of program design.
Open guideCommercial insurance planning
Evaluate the member benefit, payer policy, authorization, and practice contract before building a commercial program forecast.
Open guideRELATED TOOLS
Need a different answer?
Rates & code pathwaysStart here for the California county preview, code-family orientation, and payment guardrails.Payer-specific guidesUse this when the question is Original Medicare, Medicare Advantage, Medi-Cal, FQHC/RHC, or commercial coverage.Current pagePractice economicsUse this to test whether population, participation, staffing, contracts, and workflow make a program viable.
THE REVIEW SEQUENCE
Clinical need first. Payment pathway second.
- Define the care need. Which patients would clinically benefit, and what care work must be sustained?
- Identify the payer and arrangement. Original Medicare, Medicare Advantage, Medi-Cal, Medi-Medi, commercial, FQHC/RHC, delegated, or capitated models require different questions.
- Validate the operating evidence. Confirm the required consent, documentation, data, time, supervision, and handoffs can be delivered consistently.
- Communicate clearly with patients. Explain purpose, choice, expected contact, and any potential responsibility before enrollment.
Last reviewed: September 2026. Coverage, payment, code descriptors, managed-care policies, contracts, and patient responsibility change. Confirm current authoritative guidance and the patient’s actual plan before billing or quoting an amount.
DESIGN A PRACTICAL STARTING POINT
Tell us where the workflow is breaking. We’ll show you where to begin.
Send us a message
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