Medicare Advantage plans are health plan options (like HMOs and PPOs) approved by Medicare and run by private companies. These plans are part of the Medicare Program and are sometimes called "Part C" or "MA plans." Every month, Medicare pays an amount to these private health plans for a beneficiary's care. Medicare Advantage Plans must follow rules set by Medicare. Medicare Advantage Plans are not supplemental insurance. Medicare Advantage includes the following:
- Preferred Provider Organization (PPO) plans
- Health Maintenance Organization (HMO) plans
- Private Fee-for-Service (PFFS) plans
- Medical Savings Account (MSA) plans
- Special Needs plans (SNP)
CMS cautions MA PFFS plans re: medical record requests
The Centers for Medicare & Medicaid Services (CMS), in its final 2009 "call letter" issued on March 17, 2008, to Medicare Advantage (MA) plans, set forth clarifications regarding requests of private fee-for-service (PFFS) plans for medical records from physicians. Many Iowa physician practices have received sometimes extensive record requests from PFFS plans for the purpose of assessing the risk adjustment status of beneficiaries, which could result in higher payment to the MA PFFS plan.
CMS stopped short of mandating that PFFS plans pay a fee for the medical records but "strongly urges" PFFS plans to include clear and detailed information in their terms and conditions setting forth reasons why the PFFS plan might ask for medical records, the expected administrative burden such record requests will place on providers, and mitigating factors such as fee payment from the plan for record production.
CMS says, "PFFS plans that impose too significant a burden are in danger of causing providers to refuse access to plan members." CMS further cautions plans and providers alike that if the PFFS plan requests medical records to support a CMS-initiated risk adjustment validation audit focused on a CMS-selected subset of beneficiaries, providers are required by law to comply with such record requests and plans cannot use these produced records for any other purpose. In general, CMS advised MA plans that it will be closely monitoring both beneficiary and provider complaints.