# Gray area.  Filing a claim with Medicare vs. filing with a Group Medicare Advantage PPO



## Basilica2 (Jan 18, 2018)

You're seeing a provider who has opted out of Medicare and does not accept any private insurance.  If you have Medicare, to see him you must sign a private contract promising not to submit for reimbursement to Medicare.  He does encourage patients to submit invoices to their private insurers for possible reimbursement.  (The "why" of this is unimportant.)

Recently, your health insurance changed from Medicare/private insurer to a private insurer's Group Medicare Advantage PPO.  Before, claims went to Medicare first, then bounced over to the private insurer.  Now, claims go directly to the Group Medicare Advantage PPO, which processes the claim through Medicare and then picks up at least some of the costs Medicare doesn't cover.   

Months before your insurance changed to the Medicare Avantage PPO, you signed that contract with the provider not to submit to Medicare for reimbursement.  Would you be violating that contract by submitting a claim for reimbursement to your new private insurer?

The insurance company says, "No, you are filing with us, not Medicare, though we process it through Medicare first."  An agent of the organization that made the transition to the Medicare Advantage PPO, says, "Yes, you are  breaking your contract with the provider if you file a claim with the new insurer."

Opinions?


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