Who allows the PFFS plan to determine if balance billing is permitted?

The Centers for Medicare & Medicaid Services (CMS) is the federal agency that oversees Medicare Advantage plans, including Private Fee-for-Service (PFFS) plans. CMS has established regulations regarding balance billing, which is the practice of charging a patient for the difference between what Medicare pays and what the provider charges.

In the context of PFFS plans, CMS allows these plans to determine their own policies regarding balance billing as long as they comply with the overall guidelines set forth in Medicare regulations. Therefore, it is critical for PFFS plans to follow CMS directives when establishing whether balance billing is permitted, ensuring that their policies do not violate any Medicare rules.

This understanding highlights the importance of CMS's oversight role in shaping the operations of PFFS plans within the Medicare structure, providing a framework for their billing practices.