RPM / RTM
Is the monitoring clinically appropriate? Can the selected device or therapeutic-data workflow meet the current payer’s data, practitioner, and treatment-management requirements?
Talk with us PAYER GUIDE
Original Medicare and Medicare Advantage can support the same care need—but not the same operating plan.
Start with the patient’s clinical need. Then separate benefit coverage, the practice’s payment arrangement, the patient’s cost, and the evidence required to deliver the program well.
Review your payer mixTHE ESSENTIAL DISTINCTION
“Covered” does not automatically mean “paid to your practice in the same way.”
Medicare Advantage plans must cover medically necessary services that Original Medicare covers, but network, authorization, cost-sharing, plan policy, and the practice contract can change how a program is operationalized and paid. Use a separate decision path for each member.
| Decision point | Original Medicare | Medicare Advantage / delegated model |
|---|---|---|
| How the practice is paid | A covered, qualifying service is generally considered through the current Medicare Physician Fee Schedule and applicable local guidance. The practice still confirms eligibility, service requirements, and the locality-specific amount. | The plan must cover medically necessary services Original Medicare covers, but the practice payment path can depend on the member’s plan, network, authorization rules, delegation or capitation arrangement, and contract. |
| What the operations team checks | Beneficiary coverage, clinician and service requirements, consent, documentation, timing, frequency, non-duplication, and current contractor guidance. | Exact plan and product, in-network status, prior authorization or vendor requirements, claims instructions, benefit limits, delegation/capitation, and the contracted payment model. |
| What the patient may experience | Part B deductible and coinsurance may apply; supplemental coverage can change the patient’s responsibility. Explain the actual estimate before enrollment. | Copay, coinsurance, deductible, network, authorization, and supplemental benefits are plan-specific. Confirm the member’s actual benefit before promising an amount. |
| The executive decision | Can we deliver the care and evidence required for this patient—and does the current local payment pathway support the operating model? | Does this plan and our contract create an incremental payment path, a delegated obligation, a quality/capitation opportunity, or no viable pathway for this program? |
PROGRAM-BY-PROGRAM REVIEW
Ask a different question for each care pathway.
The patient’s benefit does not replace the clinical, documentation, and workflow test. These are useful starting questions for an administrator, medical director, or billing lead.
CCM / PCM / APCM
Who is accountable for the care plan and ongoing care? Can the team separate qualifying work from other services and explain any monthly patient responsibility?
TCM / post-discharge
Can the practice reliably receive discharge information, make timely contact, complete medication reconciliation, and document the required follow-up?
BEFORE YOU ENROLL
Use a patient-and-plan checklist.
Identify the coverage type, plan, product, network status, and whether the member has secondary coverage.
Confirm whether the practice is paid fee-for-service, delegated, capitated, value-based, or through another arrangement.
Check the current plan or Medicare requirements for authorization, vendor/device, data, documentation, billing, and frequency.
Confirm the clinical need, responsible practitioner, patient consent, and ownership of outreach, escalation, and billing evidence.
Explain the purpose, expected contact, choice to decline, and potential patient responsibility before services begin.
PRACTICE OPERATIONS
Build one eligibility record—not a generic Medicare list.
Record the payer, product, network, authorization status, program fit, consent, cost-share conversation, and workflow owner alongside the patient. This makes enrollment and claim handoff auditable.
See the implementation toolkitPATIENT EXPERIENCE
Tell patients what changes for them.
Explain who will call, why they are being contacted, which care team remains responsible, how to ask questions, and what the actual benefit check shows about their possible cost.
Use the cost-share and consent guideOFFICIAL REFERENCES
Use current member and payment information—not a generic Medicare estimate.
Medicare.gov compares the member experience of Original Medicare and Medicare Advantage, including network and prior-authorization differences. CMS publishes the Physician Fee Schedule lookup for current local payment information.
DESIGN A PRACTICAL STARTING POINT
Tell us where the workflow is breaking. We’ll show you where to begin.
Send us a message
Continue on your phoneScan to open a pre-addressed email draft.Email contact@theprimevital.com