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Medicare/ Medicaid

Module D

Who runs the medicare Program? Center of medicare and medicaid services (CMS)
how many time is an eligible person issued a card? every month
What Dose a capitalize a on a medicare mean? wage earner
What does a capitalize c a on a medicare card mean? Child or student
define Medigap or Medifill? type of supplementary insurance
Define Hospice? a program design to give pain relief, symptoms management and supportive care 2 terminally ill patients and their families
what does medicare part A cover? Inpatient Hospital coverage
how many day does medicare cover inpatients ? 90 days per benefit period
what other healthcare does medicare cover and how many days? Skilled Nursing facility up to 100 day per benefit period
What does Medicare part B cover? Outpatient coverage
what type of insurance is medicare part B ? Supplementary medical insurance
how is medicare funded ? thru Premiiums that are deducted from Social Security checks, railroad retirement checks, or civil service annuity payments
what does PPS stand for ? Prospective Payment System
How do Medicare part A figure out how much to pay for a service? Payments are based on patient's diagnosis(es) using a system call Diagnosis Related Groups (DRGs)
How do Medicare part B figure out how much to pay for a service? Payments are based on usual, customary, and reasonable charge (UCR)
What does PARS stand for ? Participating Physician Program
What does PARS program require of healthcare providers ? accept assignment on medicare claims
If a provider plans to perform an elective surgery that cost $500 or more, a financial statement must be prepared indicating the the most important thing which is ...? Patients probable out-of-pocket expense
Why should healthcare providers obtain a lifetime authorization signature? signing should be done prior to an event where you are unable to obtain a patient's signature on the Medicare claim form.
HCPCS coding system has how many levels? 3
how many Medicare supplemental polices are there? 2
Name the two Medicare supplemental polices 1. Service benefits 2. Indemnity Benefits
What order does a claim with a MSP( medicare secondary payer) get billed? to MSP first then Medicare
If the patient is still working and still receiving health insurance through employer who gets bill first medicare or employer's insurance ? employer's insurance
For a patient who has Medicare and Medicaid or medi-Medi, who is billed the claim first? Medicare then medicaid
?If a physician does NOT accept assignment on a MEdi-Medi patient what happens? payment goes to the patient
*Listing Question. List all 4 reason why a physician maybe penalized ? 1. Billing more than once for same service 2. billing for a service that they didn't provide 3.Fragmenting billed servics 4.upgrading the reported level or complexity of service.
What does (PRO) stand for ? Peer Review Organization
what does PRO do? valutes uality and appropriateness of professional care and settles fee disputes between a healthcare facility and Medicare
Service benefits ? adjust with cost increases in deductible or co-payments
Indemnity Benefits? pay a fixed dollar in deductible or co-payments
How is Medicaid pay for ? sponsored by federal, state and local governments = so each state. differs from another. TAXES Pay for it
need to know ? not all eligible patients are given the same benefits
Name the two Medicaid classifications? 1. categorically needy 2. Medically Needy
what does Qualified Medicare Beneficiaries (QMBS) mean other wise? Spouse gets free healthcare
Need to know ? Generally =, the patient never receive no bill ( anything not covered by Medicaid's payment is written off by the physician
what is Early and Periodic Screening, Diagnosis, and treatment (EPSDT) Mean ? A program of prevention early detection and treatment of welfare children(under age 21)
MCHP or Maternal and CHild Health Program do ?. provides low income mothers and children access to quality maternal and child health services.
* listing question. List some of the the Produces that must be per-approved prior to payment ? Hearing aids home healthcare Inpatient hospital care medical supplies mediations prosthetics/orthotic appliances surgical procedures transportation some vision care
listing question. List reasons in which a claim might be rejected ? Diagnosis is mising or incomplete Diagnosis is not coded correctly diagnosis does not correspond with treatment charges are not itemized Patient's ID number is missing fee is not listed dates are missing or incorrect physician's signature or addre
Created by: Lpsmarts5791