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Chapter 12 Medicare
Mod 7 Chap 12 Medicare
| Question | Answer |
|---|---|
| Medicare is administered by whom? | The Centers for Medicare and Medicaid Services (CMS) - formerly known as HCFA. |
| An individual is automatically enrolled in Medicare Parts A & B starting the first day of the month that the person turns 65 years of age if they already receive what? | Social Security or Railroad Retirement benefits |
| Medicare Part A is what? | hospital coverage |
| Medicare Part B is what? | outpatient coverage |
| For aliens, to be eligible the applicant must have done what? | must have lived in the United States as a permanent resident for 5 consecutive years |
| Letters that follow the Medicare number indicates what? | the patients status |
| Letters the preceed the Medicare number on the ID card indicates what? | railroad retirees |
| Under Medicare Part A, what is the benefit period? | begins the day a petient enters a hospital and ends when the patient has not been a bed patient in any hospital or NF for 60 consecutive days |
| Medicare Part B is considered what? | supplementary medical insurance |
| When a person is eligible for Medicare Part B and Medicaid, Medicaid pays what? | the monthly Part B premiums |
| Medicare Part C | Medicare advantage plan |
| a medicare beneficiary can join a Medicare Advantage plan if he/she has what? | both parts A and B and lives in the service area of the plan |
| Medicare Part D | provides seniors and people with disabilities with a prescription drug benefit |
| Medigap | a specialized insurance policy for Medicare beneficiaries designed to supplement coverage under fee for service plans |
| Medicare Select | variation of Medigap which has the same coverge as regular Medigap policies but beneficiary must receive care from a list of specified network providers |
| Medicare and auto or liability claims are not secondary to Medicare - true or false? | True |
| If 120 days has lapsed since billing a liability carrier without payment then the provider may do what? | may bill Medicare if services were covered Medicare benefits and must drop the liability claim |
| Name the two types of HMO plans that may have Medicare Part B contracts | 1. HMO risk plans 2. HMO cost plans |
| Participating provider (PAR) | physician who agrees to accept payment from Medicare (80% of approved charges) plus payment from the patient (20% of approved charges) after the $135 deductible is met. |
| Medicare annual deductible is based on what? | the calendar year |
| Agreement to accept payment from Medicare as payment in full is called what? | accepting assignment |
| Nonparticipating physician (non-par) | physician does not have a signed agreement with Medicare and has an option about assignment. |
| Nonpars must accept assignment for what services? | clinical lab tests and services by physician assistants |
| If a provider expects Medicare to deny payment entirely or in part, the patient must sign what? | Advance Beneficiary Notice of Noncoverage (ABN) |
| elective surgery | surgical procedure that can be scheduled in advance, is not an emergency, and is discretionary. |
| What does Correct Coding Initiative do? | attempts to eliminate unbundling or other inappropriate reporting of CPT codes |
| Prospective payment system | under Medicare part A hospitals are reimbursed according to preestablished rates for each type of illness treated on the basis of diagnosis. |
| True or false: Medicare Part A beneficiaries can not be billed beyond the preestablished DRG rate except for normal deductible and copayment amounts | true |
| What does DRG stand for? | diagnosis related group |
| RBRVS | resource-based relative value scale |
| What is RBRVS? | system Medicare uses for establishing fees |
| HCPCS - what are the two levels? | Healthcare Common Procedure Coding System Level 1 is CPT codes and modifiers (national codes) Level 2 is CMS-designated codes and alpha modifiers (national codes) |
| Medicare administrative contractors | organizations that handle claims from physicians and other suppliers of services covered under Medicare Part B |
| Fiscal intermediary | an organization handling claims from hospitals, NFs, ICFs, LTCFs and home health agencies |
| What is the time limit for filing a Medicare claim? | the end of the calendar year after the fiscal year in which services were furnished. Fiscal year for claims begins Oct 1 and ends Sept 30 |
| Medicare regulations require that a patient be billed for a copayment at least how many times before the balance is adjusted off? | three times |
| a person becomes eligible for Medicare Parts A and B at what age? | 65 |
| Medicare Part A is what type of coverage? | hospital |
| Medicare Part B is what type of coverage? | outpatient/medical |
| name an eligibility requirement that would allow aliens to receive Medicare benefits | applicant must have lived in the U.S. for 5 consecutive years |
| Funding for the Medicare Part A program is obtained from whom? | special contributions from employees and self-employed with employer matching contributions |
| funding for the Medicare part B program is obtained equally from whom? | those who sign up for it and the federal government |
| program designed to provide pain relief, symptom management, and supportive services to terminally ill and their families is what? | hospice |
| short-term inpatient medical care for terminally ill individuals to give temporary relief to the caregiver is known as what? | respite care |
| the frequency of pap tests for Medicare patients is what? | once every 24 months for low risk beneficiaries and 12 months for high risk |
| policies that fall under guidelines issued by the federal government and may cover prescription costs, Medicare deductibles and copayments are secondary or supplemental policies called what? | Medigap insurance policies |
| Name two types of HMO plans that may have Medicare part B contracts | 1. Risk plan 2. Cost plan |
| the federal laws establishing standards of quality control and safety measures in clinical labs are known as what? | CLIA |
| acceptance of assignment by a participating physician means that he or she agrees to what after the $135 deductible is met? | accept the 80% approved amount and 20% approved amount from the patient. |
| an operative procedure scheduled in the future is referred to as what? | elective |
| organizations or claims processors under contract to the federal government that handle insurance claims and payments for hospitals under Medicare Part A are known as what? | fiscal intermediaries |
| organizations that process claims for physicians and other suppliers of services under Medicare Part B are called what? | medicare administrative contractors (MAC) |
| a CMS assigned provider ID # is know as what? | NPI |
| physicians who supply durable medical equipment must have what ID number? | DME |
| if circumstances make it impossible to get a signature each time a paper claim is submitted or electronic claim transmitted, the Medicare patient's signature may be either | annual signature authorization or sign claim form block 12 & 13 and keep on file |
| If a patient with MediMedi claim submitted and the assignment portion is left blank in error what happens? | payment goes to the patient and Medi-Cal does not pick up residual |
| if a person age 65 has Medicare, is working and has a group insurance policy, where is the insurance claim form sent initially? | the group carrier |
| if a Medicare patient is injured in an auto accident, the physician submits the claim form to who? | the 3rd party liability carrier |
| medicare prescription drug benefits for those who purchase the insurance are available under what? | Medicare Part D |
| Medicare secondary payer cases may involve what? | medicare-aged workers in a group health plan of more than 20 covered employees; medicare-aged or disabled who also receive benefits under the Dept. of VA; medicare patient involved in an automobile accident |
| if a medicare patient is to receive a medical service that may be denied payment either entirely or partially, the provider should what? | have the patient sign an advance beneficiary notice (ABN) |
| a decision by a MAC whether to cover a medical service on a contractor-wide basis in accordance with whether it is reasonable and necessary is known as what? | local coverage determination |
| according to regulations, a Medicare patient must be billed for a copayment at least how many times before a balance is adjusted off as uncollectible? | at least three times |
| true or false: all patients who have a Medicare ID card have Part A and Part B | false |
| true or false: Prescription drug plans refer to the drugs in their formularies by tier numbers | true |
| true or false: nonpar physicians may decide on a case-by-case basis whether to accept assignment when providing medical services to Medicare patients | true |
| medicare's correct coding initiative was implemented by CMS to eliminate unbundling of CPT codes | true |
| true or false: a medicare/medigap claim is not called a crossover claim | false |
Created by:
mpeoples