Medicare Advantage Billing ProTips That Will Boost Your Revenue


Is your eye care practice struggling with an increase in Medicare Advantage claim denials? Not sure how to keep up and capitalize on the growing popularity of Medicare Advantage plans versus traditional Medicare?

More than 33% (19.0 million) of Medicare beneficiaries in the U.S. are enrolled in a Medicare Advantage (also known as MA, Medicare Part C, or Medicare replacement) plan, and enrollments continue to grow each year. 

According to the Congressional Budget Office projections, more than 41% of all Medicare beneficiaries will be enrolled in a Medicare Advantage plan nationwide by 2026. Only 2% of Medicare Advantage enrollees each year voluntarily switch back to traditional Medicare. 

Depending on your state or even your city, the number of Medicare patients enrolled in a Medicare Advantage plan can vary: from about 1% in Alaska to 45% in Hawaii. The top six states for Medicare Advantage beneficiaries in 2017, reported by the Kaiser Family Foundation are MN (56%), HI (45%), OR (44%), FL (42%), PA (41%) and CA (40%).

Ready to reduce claim denials and boost your Medicare Advantage revenue? Let’s examine common billing requirements and tips that will improve the financial health of your eye care practice.

Medicare Advantage Billing Requirements You Can’t Ignore

Medicare Advantage Plans Follow CMS Rules: Medicare Advantage plans are offered through private insurance companies. These plans must be approved by Medicare and follow the Centers for Medicare and Medicaid Services (CMS) rules regarding billing, coding, claims submission, and reimbursement.

Medicare Advantage plan options include health maintenance organizations (HMO), preferred provider organizations (PPO), private fee-for-service (FFS) plans, special needs plans, and Medicare medical savings accounts (MSA) plans.

Medicare Advantage Plans are Not Supplemental Plans: Medicare Advantage plans must cover all traditional Medicare services, including Part A (hospital insurance) and Part B (medical insurance) coverage. Most plans cover Part D coverage (prescription drugs). If a patient has a Medicare Advantage plan, do not bill traditional Medicare. Do not confuse Medicare Advantage plans with supplemental plans that are billed after Medicare pays.

Vision Benefits Vary from Plan to Plan: Many Medicare Advantage plans offer extra coverage for vision-related items or services, such as preventive and routine vision coverage, eyeglasses, and intraocular lenses (IOLs) related services. Vision benefits and coverage vary from plan to plan, and rules can change every year. Each Medicare Advantage plan charges different out-of-pocket fees and has rules for how you get paid for your services. 

Provider Payments: Medicare Advantage payers usually pay providers on a per member per month (PMPM), partial or full-capitation, or a percent-of-revenue basis.

Risk-Based Medicare Advantage and MIPS: Currently, eligible clinicians (ECs) participating in at-risk Medicare Advantage plans must still report in the Merit-Based Incentive Payment System (MIPS) program. CMS recently announced proposed changes to the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration that would waive MIPS requirements for ECs participating in at-risk Medicare Advantage plans. 

Common Medicare Advantage Billing Challenges and Solutions

By implementing advanced billing processes in your practice, you have the power to boost your business revenue and get paid faster. At Fast Pay Health, we’re experts at helping you transition from cumbersome patient verification, eligibility, and insurance billing processes with a more straightforward approach to eye care billing management.

Let’s examine a five-doctor optometry practice that Fast Pay Health works with and how an efficient billing solution turned into a definite “win-win” outcome for both the practice and patients.    


  • Reduce denied claims due to billing traditional Medicare instead of Medicare Advantage.

  • Verify the patient is enrolled in Medicare or Medicare Advantage.

  • Determine when to file a claim with a supplemental vision insurance plan.

Solutions and Outcomes:

  • Analyze denied claims based on appointment date (service date).

  • Verify patient demographic information, insurance plan data, and policy effective and term dates are correct before submitting the claim, as well as verify co-pays for exam and materials for vision insurance plans.

  • Refile denied Medicare claims to Medicare Advantage (if vision benefits are available).

  • Outcome: Higher payments, fewer denials, faster turnaround, and lower accounts receivable.

ProTips for Processing More Efficient Medicare Advantage Claims

Verify Patient’s Insurance Benefits and Check Eligibility: To avoid costly delays in claim rejections and denials, it’s important to always verify every patient’s insurance plan information before their visit. Some patients might not even realize they are enrolled in a Medicare Advantage plan and may only give you their Medicare card.

By checking eligibility in advance, your office can ensure claims are filed to the correct payer right after the patient’s visit. You might even find the patient has additional vision coverage through another vision insurance plan they weren’t even aware they had. Medicare keeps a record of reported “crossover plans,” including supplemental coverage or vision insurance plans so that a quick eligibility check can save time down the line.

Related: How to Reduce the Accounts Receivable Cycle with Smarter Billing

Related: 6 Eye Care Billing Rejections You Can Overcome

Don’t Get Lost in Payer Portals: When it comes to checking eligibility and benefits verification though, it’s easy to get lost in the different payer portals or Interactive Voice Response (IVR) systems. Verifying a patient’s insurance eligibility and benefits is a critical first step. A revenue cycle management service like Fast Pay Health offers support by tackling the insurance eligibility and benefits verification process—saving you and your staff time and money. 

“Our Fast Pay Health team understands the field of optometry and the nuances of optometry medical claims. Plus, they have extensive experience with Medicare and secondary insurances specific to optometry, and regularly make suggestions for corrections.” – Julie Honda, OD

Related: How Efficient Optometry Billing Eased Stress for a Busy Practice

Boost Your Business Revenue with an Efficient Billing Service

The financial health of your eye care practice depends on higher efficiency and revenue cycle management (RCM) support. At Fast Pay Health, our prescription for your practice is smarter, full-service RCM solutions. We know the ins and outs of your insurance payers best, and we work with ANY practice management software.

Request a free revenue cycle management practice analysis today to see how we can reduce the accounts receivable cycle with smarter billing. Let us take care of the billing hassles, so you have more time with your patients.