PAYER GUIDE

Original Medicare vs. Medicare Advantage: similar benefit language, different operational questions.

For care-management and monitoring programs, the reimbursement path is determined by more than the service name. The member’s coverage arrangement and the practice’s contract matter.

Review your payer mix

THE ESSENTIAL DISTINCTION

“Covered” does not automatically mean “paid to your practice in the same way.”

Original Medicare and Medicare Advantage should be evaluated separately at the patient level. PrimeVital helps organize the operational questions; the provider organization confirms the final clinical, coding, and contract interpretation.

Original Medicare

Begin with the current federal coverage and coding requirements, then confirm the applicable local fee-schedule amount, patient eligibility, documentation, and any Local Coverage Determination or contractor guidance.

Medicare Advantage / IPA

Start with the member’s plan, network, delegation or capitation arrangement, authorization requirements, medical policy, and the practice’s contract. Do not assume a physician-fee-schedule pathway creates incremental fee-for-service payment.

BEFORE YOU ENROLL

Use a patient-and-plan checklist.

Identify the patient’s coverage type, plan, product, and network status.

Confirm whether the practice is paid fee-for-service, delegated, capitated, or through another arrangement.

Check plan-specific authorization, vendor, data, documentation, and billing requirements.

Confirm the clinical need, responsible practitioner, patient consent, and workflow ownership.

Discuss potential patient responsibility before services begin.

OFFICIAL REFERENCE

Use the current CMS payment and coverage resources.

CMS publishes the Medicare Physician Fee Schedule search and remote patient monitoring guidance. Local payment amounts and contractor interpretation can differ from national assumptions.

Open the CMS Physician Fee Schedule

DESIGN A PRACTICAL STARTING POINT

Tell us where the workflow is breaking. We’ll show you where to begin.

Choose how to connect

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