Whitepaper · Eye care · Medicare Advantage and IPAs
Your MA contract says one number. The remittance says another.
Medicare Advantage plans and IPAs pay eye groups off contract schedules that usually point at Medicare. When Medicare moves, as it does on 1 January 2027, the gap between what the contract says and what the plan pays can open quietly. This is how to measure it and get it back.
By ASP-RCM Editorial, Healthcare RCM Practice · Updated
The question for your managed care lead
Does your contract pay a percent of current-year Medicare, or of a fixed year, and does the plan's system know which?
CY2027 Medicare conversion factor
Non-qualifying APM, down 2.31% from $33.40 (CMS-1848-F)
Of Original Medicare for non-contracted
What a non-contracted provider must accept, and the plan must pay (42 CFR 422.214)
To request MA reconsideration
From the date of the notice, per CMS; the regulation counts 60 days from presumed receipt
Same-day E/M or 0-day procedure
The lower-paid service from 1 Jan 2027 when an office E/M and a 0-day global procedure share a day
How to measure underpayment
Compare what the contract says against what was allowed, line by line. Paid alone hides cost share and secondary payments.
Load the contract terms
Fee schedule exhibit, Medicare year it points to, percent, locality, and any carve-outs for drugs or surgery.
Price every line
Contract-expected allowed per code, modifier, units and place of service, using the right Medicare year.
Compare to allowed
Use the allowed amount from the 835, not the payment. Patient cost share and secondary payers sit inside allowed.
Group the variance
By payer, IPA, code and month. One wrong rate load shows up as the same short pay on every line.
Dispute by the right route
Contract dispute for contracted lines, reconsideration for non-contracted, state dispute process for California IPAs.
Three contract types, three ways to go wrong in 2027
| Contract language | What it should pay in 2027 | Common error |
|---|---|---|
| Percent of current-year Medicare | Moves with the CY2027 rates, so most eye codes fall | Plan keeps paying 2026 rates, or applies the cut before 1 January |
| Percent of a fixed Medicare year | Stays at the named year's rates | Plan loads 2027 Medicare rates anyway and short pays every line |
| Fixed dollar fee schedule | The listed amounts, unchanged | Codes missing from the exhibit priced at a default percent |
Worked example: 2027 national Medicare amounts for common eye codes
Illustration, not a client result. National amounts from the CY2027 PFS final rule, before geographic adjustment. Your locality differs.
| Code | Setting | CY2026 | CY2027 | Change |
|---|---|---|---|---|
| 92014 comprehensive eye exam, established | Office | $127.26 | $120.40 | -5% |
| 99214 office visit, established | Office | $135.61 | $131.17 | -3% |
| 66821 YAG capsulotomy | Office | $335.35 | $316.82 | -6% |
| 66984 cataract with IOL | Facility | $462.60 | $442.12 | -4% |
| 67028 intravitreal injection | Office | n/a | $108.65 | 0-day global |
Source: CMS-1848-F Impact on Payment for Selected Procedures (CY2026 at $33.4009, CY2027 at $32.6286). 67028 from CY2027 Addendum B total non-facility RVUs (3.33) times $32.6286.
Worked example: short pay per line if a fixed-year contract is priced on 2027
Illustration, not a client result. Contract pays 110% of 2026 Medicare; the plan loads 110% of 2027. National amounts, no locality.
Multiply by your annual volume per code to size the gap. The same arithmetic in reverse shows an overpayment if a current-year contract is still priced on 2026.
Contracted vs non-contracted MA claims
Your rights depend on whether you hold a contract with that MA plan or its delegated group.
Contracted
- Rate and timing come from your contract's terms (42 CFR 422.520(b))
- Payment disputes follow the contract dispute clause
- In California, IPA claims under a Knox-Keene licensed plan can also use the state dispute process
- Keep the signed fee schedule exhibit and its Medicare year
Non-contracted
- Plan must pay at least what Original Medicare would pay (42 CFR 422.214)
- 95% of clean claims paid within 30 days, with interest after; all others within 60 days
- Payment denials go to reconsideration, 65 days from the notice
- A signed waiver of liability holding the patient harmless is required
Worked example: the 2027 same-day rule on a retina visit
Illustration, not a client result. National office amounts.
Two services, one day
99214 with modifier 25 at $131.17 and 67028 at $108.65, same physician, same day.
The lower-paid line drops
67028 is paid at 80%: $86.92, a reduction of $21.73 on the visit under Medicare's 2027 rule.
What it means for MA
Non-contracted MA claims follow Original Medicare amounts. Contracted claims follow whatever payment policy your contract adopts. Check before you call it underpaid.
Dispute routes and clocks
| Situation | Route | Clock |
|---|---|---|
| Non-contracted MA payment denial | Reconsideration with the MA plan, with a signed waiver of liability | Request within 65 days of the notice; plan decides payment requests within 60 calendar days |
| Non-contracted MA paid below Original Medicare | Payment dispute with the plan; CMS expects plans to resolve these promptly | Raise it with the plan and keep the Original Medicare calculation |
| Contracted MA underpayment | Contract dispute process | As your contract states |
| California IPA or Knox-Keene plan underpayment | Provider dispute under 28 CCR 1300.71.38 | 365 days from the last action; decision within 45 working days |
A non-contracted MA reconsideration
- Notice date
Remittance or denial notice issued. Receipt is presumed 5 days later.
- Before day 65
File reconsideration in writing with the signed waiver of liability. Without it the plan should not start its review.
- 60 days after receipt
Plan decides a payment reconsideration.
- Late filing
Good cause. The plan may extend the filing time if you show good cause in writing.
Data you need before you dispute
Signed contract and exhibits
Including amendments and the Medicare year or fee schedule version each one names.
835 allowed by line
Allowed, paid, patient share and adjustment codes for every line, not just totals.
Medicare pricing for the date of service
The right year, locality and setting. Facility and office amounts differ.
A pattern, not one claim
Group lines by code and month. A systemic rate error is easier to settle than one claim at a time.
Score your MA and IPA underpayment control
Price every MA and IPA line against the contract, not against last month's payment. In January 2027, check each payer's rate load against the Medicare year your contract names. Non-contracted claims are owed at least Original Medicare. Dispute patterns, on the right route and inside the clock. See the 2027 fee schedule for ophthalmology.
Questions operators ask next
How much must a Medicare Advantage plan pay a non-contracted eye doctor?
Under 42 CFR 422.214, a provider without a contract with the MA plan must accept, as payment in full, what it could collect if the patient were in Original Medicare. CMS says plans must pay non-contract providers no less than the Original Medicare amount. Patient cost share is part of that total.
What is the deadline to appeal a Medicare Advantage payment denial?
CMS says a reconsideration must be filed within 65 calendar days from the date of the notice. The regulation counts 60 days from receipt, with receipt presumed 5 days after the notice. Non-contracted providers must include a signed waiver of liability. The plan decides payment reconsiderations within 60 calendar days.
Does the 2027 Medicare cut change my Medicare Advantage rates?
It depends on the contract. If it pays a percent of current-year Medicare, rates follow the CY2027 fee schedule, where the conversion factor fell 2.31% to $32.63. If it names a fixed Medicare year or dollar schedule, the 2027 cut should not change what you are paid. Check how each plan loaded its rates.
How fast must a Medicare Advantage plan pay a non-contracted claim?
Under 42 CFR 422.520, the plan must pay 95% of clean claims from non-contracted providers within 30 days of receipt, with interest on clean claims paid later. All other non-contracted claims must be paid or denied within 60 calendar days. Contracted providers are paid under the prompt pay terms in their own contract.
Measure what your MA plans and IPAs owe you.
Send us 90 days of MA and IPA remittances with your fee schedule exhibits. A senior eye care billing lead compares contract-expected allowed to paid by code and payer, and walks you through the variance and the dispute clocks in a free 30-minute call.
Keep reading
Sources
- CMS, CY2027 Medicare Physician Fee Schedule final rule fact sheet
- CMS, CMS-1848-F rule page: Addendum B and Impact on Payment for Selected Procedures
- eCFR, 42 CFR 422.214, services furnished by noncontract providers
- eCFR, 42 CFR 422.520, prompt payment by MA organization
- eCFR, 42 CFR 422.582, request for a standard reconsideration
- CMS, Reconsideration by the Medicare Advantage health plan (Part C)
- CMS, Provider Payment Dispute Resolution for Non-Contracted Providers
- CMS, Medicare Managed Care Manual transmittal R105, non-contract provider appeals and waiver of liability
Checked November 6, 2026. Dollar figures are CMS national amounts used as an illustration, not a client result or a promise of recovery. Your contracts, localities and payer policies govern. General information, not legal advice.