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Medicare-Chapter 12

From Fordney's Insurance Handbook

Medicare is a federal insurance program consisting of parts...? A(Hospital coverage), B (Medical & preventive care/suplemental medical insurance), C (Advantage plan/Medicare plus), and D (Prescription drug coverage).
Who runs Medicare (MCR)? The centers for Medicare and Medicaid Services. It is also called CMS.
What are the three divisions of CMS (Centers for Medicare and Medicaid Services)? 1. The Center for Medicare management 2. The Center for Beneficiary Choices 3. The Center for Medicaid & State operations
What does the Center for Medicare Management do? It is the policymaker for the traditional fee-for-service Medicare.
What does the Center for Beneficiary Choices do? It provides information to members of Medicare. Members are called beneficiaries.
What does the Center for Medicaid and State Operations do? It manages federal-state programs such as Medicaid, SCHIP, insurance regulations and CLIA.
What else does CMS enforce? It enforces insurance portability and insurance transaction. It also enforces code set requirements of HIPAA.
What are the three ways to be eligible for Medicare? 1.Be retired from working,receive SS & be 65yrs old. 2. Be retired from the RR/civil service & be 65yrs old. 3. Be a disabled worker any age who is eligible for SS benefits.
Can you receive Medicare if you are not 65? Yes, you can recieve Medicare at any age if you are disabled & have received SS for 24 months or your parents have been receiving SS benefits. If you are in End Stage Renal Disease requiring a transplant or are a kidney donor.
Who eligible to receive Medicare part A free of charge? Everyone! This is determined by the Social Security Administration.
How is the fee/premium for Medicare part B determined? It is paid annually and it the fee increases based on age. (For example a 65 year old beneficiary would have a lower premium than a 78 year old beneficiary.)
How do most people receiving Medicare part B pay for their premium? Most beneficiaries have their premium deducted from their monthly SS check so they don't have to have to make a monthly payment.
Can a beneficiary who is not eligible for Medicare part A receive Medicare part B? Yes, they may purchase Medicare part B from the Social Security administration.
How is Medicare part A funded? It is funded by special contributions from employees, self-employed and employer matching contributions.
Are Resident Aliens/green card holders eligible for Medicare part A and B? Yes, if they have lived in the United States for at least 5 consecutive years.
What are some characteristics of a Medicare card? If issued before 1990 it is a white paper card. If issued after 1990 it can be a plastic card.
After October 1, 2012 does the beneficiaries name have to match exactly what is printed on the card? YES!
What does the Medicare claim number look like? The Medicare claim number is the beneficiaries SS number. If it has a letter at the end of the number, this person has an insufficient number of SS work credits and receives Medicare benefits based on a family member's SS work credits.(Spouse, parent etc)
Do Medicare parts A and B have the same effective dates? Not always. They can be different. Part B coverage may have a future date so be sure to read the card!
What does it mean if the Medicare claim number BEGINS with a letter? This beneficiary is a railroad retiree.
What is the general enrollment period for Medicare? January 1st through March 31st each year. The period ends 3 months after the month in which the person being enrolled turns 65.
The benefit period for Medicare part A (hospital benefits) is ...? It begins the day the patient enters a hospital/nursing facility and ends when the patient has not been a bed patient for 60 consecutive days.
What is the amount of benefit periods a patient can have in Medicare part A? Unlimited.
Medicare part B covers medical and preventative care. It is suplementary medical insurance for the aged and disabled. How is it funded? It is funded by those who sign up for it and the federal government equally.
Which part of Medicare covers the following:a physical examination when performed w/in 12 months of enrollment, diagnostic tests, mammograms once a year, some chiropractic services and has an annual `deductible of $162? Medicare part B.
Can a physician bill a patient for noncovered services? Yes, not all services are automatically covered.
What is Medicare part C? And what plan types does it include? Medicare Advantage plan. It was created to increase the number of healthcare options. Plan types: HMO, POS,PPO, PFFS, PSO, RFBS, and MSA. Some of these plans require members to pay a premium.
What is Medicare part D and how do you enroll? Prescription drug coverage. It began in 2006. To enroll either join a Medicare prescription drug plan or join a Medicare Advantage plan that includes prescription drugs as part of the plan. Both options have a monthly premium.
Benefits of medigap/medifill policies do not vary from state to state. Basically what is Medigap/medifill? And how does it benefit clients who have it? Beneficiaries who have Medigap/medifill are 65 years old, employed and have major medical insurance or Medicare as their primary or secondary insurance. Medigap/medifill may cover a deductible that is not covered by Medicare.
What type of patients are designated as Medicare and Medicaid simultaneously? These patients qualify for Old age, survivors, & disability insurance assistance(OASDI)are older than 65 yrs old and are severely disabled or blind.
What does is covered for patients with Medicare and Medicaid? Supplement coverage under a fee-for-service Medicare plan which may cover prescriptions, deductibles & copayments. These plans are purchased from private payers at cost.
What does Medi/Medi stand for? Medigap and Medifill coverage.
Medicare is a second party payer for aged or disabled patients in the following situations: Aged workers w/ group ins with less than 20 employees; Disabled patients aged 64 & younger w/ group ins with more than 100 employees or are covered under a family members employment. Workers comp when injury/illness occur at work.
Medicare is a second party payer for aged/disabled patients also in these situations: Medicare beneficiaries under an employer sponsored group plan that have end stage renal disease during the first 18 months of Medicare eligibility. Patients receiving benefits from the VA and Medicare. Patients covered under Federal research grant program
Medicare is a second party payer for aged/disabled patients also in these situations: Patients either currently/formerly employed with black lung disease who are in the federal program for the same diseases. Automobile accident cases such as medical no-fault & third party liability insurance cases.
What are Medicare HMO's also known as? Senior plans/Senior HMS.
What is the advantage of having a Medicare HMO? The beneficiary does not usually need a secondary insurance. There is a monthly premium, but you receive coverage you would not usually get from a traditional Medicare plan. Like eyeglasses, prescriptions, & routine physical exams.
Who services patients of HMO risk plans? Contracted providers except in emergency cases, urgent needs and for prior authorizations.
What are HMO cost plans and what are the patients called? Plans where Medicare beneficiaries receive Medicare covered services from sources in or out of the HMO network. Enrollees are referred to as unrestricted beneficiaries.
What happens if a non-contact physician treats a Medicare HMO patient? The services are considered out of plan. If the HMO determines there was no emergency then the payment is denied and the patient is responsible for the fee.
What is the Quality Improvement Organization or QIO? A program that contracts with the Centers of Medicare and Medicaid that reviews medical necessity and the appropriateness of inpatient medical care.
What is the Federal Claims Amendment Act? A federal law designed to prevent overuse of services and to spot fraud.
What is a whistle-blower and what is Qui Tam action? A whistle-blower is a person who informs the federal government of suspected fraud by a physician. They may receive 15-25% of any judgements; this is Qui Tam action.
What are the Clinical Laboratory Improvement Amendments (CLIA)? They were established in 1988 for standards, quality control and safety measures for all freestanding laboratories including those in physician offices. A wavier can be issued for particular tests in some cases in physician offices.
How do participating providers work with CLIA? They agree to accept assignment after the annual deductible has been met; agree to accept 80% of the allowable charge from Medicare; agree to accept 20% of the allowable charge from the patient or supplemental insurance.
What do Medicare participating providers agree to when they accept assignment? To accept 80% of the allowable charge & accept 20% of the allowable charge from the patient or secondary insurance. Both charges are after the $162 deductible is met.
What does the Civil Monetary Penalties Law do? It carries a sanction for a penalty of $2500 for a physician who fails to electronically transmit or manually submit a Medicare claim on the behalf of a Medicare beneficiary.
A Non-participating provider... does not sign an agreement w/ Medicare, but they have the option to accept on a case by case basis.
What happens if a non-participating provider does not take assignment on a particular claim? They may balance bill the patient for no more than 115% of the nonpar rate. This means a nonparticipating physician cannot bill any fee they want.
What is a limiting charge? A percentage limit on fees specified by legislation. A nonparticipating physician may bill no more than the Medicare limiting charge.
Explain the wavier of liability provision A service may be denied for medical necessity or because of limitation of liability by Medicare. For certain procedures Medicare limits the number of times a given procedure can be billed during a specific time frame.
When should the patient sign an Advance beneficiary notice of non-coverage (ABN)? If it is suspected that Medicare might deny payment entirely or in part.
What are non covered services? Services that Medicare never covers. A patient must be given a notice of exclusion from Medicare benefits which states that the service is never covered by Medicare and the patient is responsible.
Elective surgery estimates: A non-participating physician must provide the beneficiary the following in writing: estimated fee for elective surgery, estimated Medicare approved allowance, the cost difference between the approved allowance and the Medicare limiting charge.
What is a Medicare prepayment screen? A Medicare prepayment screen identifies claims to review for medical necessity and monitors the number of times given procedures can be billed during a specific time frame.
Explain the Medicare Correct Coding Initiative (CCI): Implemented by CMS through federal legislation to eliminate unbundling or other inappropriate reporting of CPT codes. Coding conflicts are picked up & claims are reviewed, suspended or denied when conflict occurs. CCI=free on CMS website.
Medicare reimbursement: under prospective payment system(pps), hospitals treating Medicare patients are reimbursed according to pre-established rates of each type of illness based on diagnosis(DRGs). cont.. Payments to hospitals for Medicare services are classified into more than 700 diagnosis related groups which made hospitals economize.
What is the Deficit Reduction Act and when was it established? The act established a participating physician program that offered incentives to participating physicians and froze the fees of nonparticipating physicians. It was established in 1984.
What is OBRA? The 1987 Omnibus Budget Reconciliation Act established the maximum charge (MAAC).
Explain what a "reasonable fee" is: The amount Medicare par-providers agree to accept. It is listed on RA or Medicare Remittance Advice Document. If accept assignment: they bill pt 20% of allowed charge, Medicare pays 80%. Cannot charge for completion/submission of a claim form.
Explain RVRVS/Resource Based Relative Value Scale: How Medicare establishes fees. It is based on work, overhead expense, & malpractice values for all of the CPT codes that are published in the Federal Register each November.
Explain PQRI/Physician Quality Reporting Initiative: A pay for reporting program for provider who bills under Medicare part B. It is a financial incentive for eligible professionals who choose to participate&successfully report on a designated set of quality measures for services paid under Medicare fee schedule/between specific dates.
Explain RAC/Recovery Audit Contractor: Identifies Medicare underpayments/overpayments and it recovers overpayments. It is done electronically w/o human review. Complex review is done w/ contractor reviewing medical record. If both payments are found the RAC will offset these amounts. Overpayment-interest accrues from date of determination, all monies must be refunded.
Explain LCD/Local Determination Coverage: Decision by MAC(Medicare Admin. Contractor) whether to cover a particular service on a contractor-wide basis in accordance w/ SS admin. LCD's outline how contractors review claims to determine whether Medicare coverage requirements have been met.
Explain FI/Fiscal Intermediary: An organization that handles claims for hospitals, nursing facilities, intermediate care facilities, long term care facilities and home health agencies. The National Blue Cross Assoc. holds the Fiscal Intermediary contract for Medicare part A and in turn it subcontracts it out to member agencies.
MACs (Medicare Admin. Contractors) are organizations that handle claims for physicians/other suppliers under Medicare part B. Medicare part B payments are handled by private insurance organizations under contract w/ the gov. The MAC for IL is Wisconsin Physicians Service in Madison, WI. Medicare part B insurance payments are NOT handled by the National Blue Cross Association.
National Provider Identifiers (NPIs): Used since May 23, 2007. NPIs are assigned by the Centers of Medicare and Medicaid. They are used as unique identifiers on claims.
DME? Durable Medical Equipment numbers are required for suppliers of medical equipment.
What is TEFRA? Tax Equity and Fiscal Responsibility Act
Patient's signature authorization: signatures for transmitting electronic claims and acceptance of financial responsibility must be obtained and retained in the office records because there are no handwritten signatures on electronic claims. (SOF) A patients's authorized signature is not required on Medicare-Medicaid cases as these crossover claims do not require the patient's signature. For Medigap claim, when transmitting a crossover claim to a Medigap carrier,annually obtain a SOF from patient.
What are the time limits for claims? Since October 1, 2009, claims must be submitted by the end of the calendar year following the fiscal year in which the services were performed per the table on page 451 in the textbook.
Assigned claims: The provider may file w/o penalty up to 27 months after providing service if reasonable cause for delay is shown to the insurance carrier, otherwise there is a 10% penalty.
Patients are not allowed to submit paper claims to Medicare except... 1.services covered by Medicare for which the pt has other insurance that should pay 1st 2.services provided by a physician who refuses to transmit the claim 3. services provided outside the US 4. situations in which DME is purchased from private source.
Medicare electronic claims: Medicare requests that all providers submit claims electronically using version 5010.
Medicare/Medicaid: Medi-Medi patients qualify for both benefits. If the physician does not accept assignment, payment goes to the patient and Medicaid will pick up the residual. CMS 1500 will be crossed over/processed automatically. Called crossover claim
Medicare/Medigap: Medicare transmits Medigap claims electronically for participating physicians when Medigap info is provided on Medicare claim. Medigap payments go directly to the provider. When a Medicare carrier transmits a Medigap claim electronically to Medigap carrier also called crossover claim.
Medicare & Supplemental Insurance Claims: some patients have supplemental coverage w/ complimentary benefits by employer plans even after retirement. In some cases, this coverage may be paid by a former employer after retirement. It can be difficult at times to determine if Medicare is the primary or secondary payer. If Medicare is primary & Medigap is secondary follow the Medi/Medi guidelines.
Claims for deceased patients with a participating provider: Participating provider accepts assignment on claim form. No signature of a family member is necessary. Type patient died on blank in block 12 instead of signature or SOF.
Claims for deceased patients with a non-participating provider: 1.An estate rep signature must be provided in order to know who is responsible for the bill 2. a statement/claim for all service provided 3. name & address of the responsible party 4. provider's statement(signed, dated)refusing to accept assignment.
(Physician substitute coverage)Reciprocal arrangement: When transmitting Medicare claims, the regular physician must identify the service provided by a substitute doctor by listing -Q5 after the procedure code.
Locum tenens arrangement: When transmitting locum tenens claims, the regular physician must identify the service with a -Q6 modifier after the procedure code.
Remittance Advice(RA): Medicare sends a payment & an RA. If the patient has Medigap or crossover coverage the payer statement reflects whether the claim has been transferred to the supplemental insurer. Non-par physicians also receive an RA w/ payment info about unassigned claims. When RA received by Medicare, billing specialist should post pt. name and amount of payment on day sheet/pt. ledger card.
Medicare Summary Notice (MSN) The patient is mailed a medicare Summary Notice so that they know how a claim was paid or not paid.
Claims Assistance Professional (CAP) A claims assistance professional may act on the Medicare beneficiary's behalf as a client representative because they have some legal standing.
Posting payments:usually a physician's charge is higher than those approved by the MAC. Payments are established by RBRVs. Medicare does not allow for standardized waiving of copayment. Medicare regulations require that a pt. be billed for the copayment least 3 times before the balance is written off. Medicare overpayments can occur due to several situations.
Situations where Medicare overpayments can occur: Carrier processed the claim more than once, physician receives duplicate payments from Medicare and a secondary carrier, the physician is paid directly on an unassigned claim, overpayment is detected=payment sent back to Medicare.
Created by: sophie4335