Practice Management

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  • 1.  Out of Area BCBS Medicare Advantage when there is No Local BCBS MA plan

    Posted 12-19-2024 11:20

    Our local BCBS carrier in Kansas City is dropping Medicare Advantage effective January 1.  I'm wondering how this is going to work if we see out of area BCBS MA patients with no MA contract.  The local BCBS carrier is saying we'll still submit MA claims to them, but I gather they will be priced as out of network claims since there is no MA contract in place.  I'm wondering if the MA carriers will give in network benefits since there are no local contracted providers.

    Does anyone work in an area where the local BCBS plan doesn't offer Medicare Advantage contracts?  If so, what has been your experience with out of area BCBS Medicare Advantage patients?  Are they getting out of network or in network benefits?  How is pre-auth working?  Any other issues?

    Thanks for any intel.

    Dave



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    David Smith FACMPE
    Executive Director
    United Imaging Consultants
    Mission KS
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    Spectrum Management Services Company: We guarantee radiology practices improved profitability, increased efficiency, and trusted expertise.


  • 2.  RE: Out of Area BCBS Medicare Advantage when there is No Local BCBS MA plan

    Posted 12-30-2024 10:55

    Hey Dave,

    Interesting question.  I haven't run into this before but in theory the out of network allowable should be 100% Medicare.  MA Out of network benefits can be very limited and large cost share to the patient.  In this case I would think BCBS would do the right thing by their patients.

    Curious to know how this turns out so please keep us posted.

    As an aside, Humana has exited the commercial side and are now 100% MA in our region.  I'm told MA business is very lucrative for these carriers (more so than commercial business in many markets) so it does seem odd that BCBS would leave voluntarily.



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    Neale Pashley
    Vice President, Partner Services
    Radiology & Imaging Specialists
    Lakeland FL
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    Spectrum Management Services Company: We guarantee radiology practices improved profitability, increased efficiency, and trusted expertise.