Chapter 9 Medicare

 Federal program  Managed by CMS under DHHS  Primarily for retired over 65 Who pays for Medicare?

Eligible People  65 or older who have paid in  Disabled adults on SS  Disabled under age of 18 meeting SS requirements  Retired Civil Service Retirement System employees and spouses  End-stage renal disease patients

Medicare Part A (automatic)  Hospital insurance for SS beneficiaries 65+  Inpatient hospital  Skilled nursing facility  Home healthcare  Hospice  Those 65+ not eligible for SS may pay premium for coverage

Medicare Part B (must enroll) Voluntary  Supplemental Medical Insurance  Outpatient hospital  Physician services  Medical equipment and supplies  Eligible people must enroll—voluntary  Monthly premium based on SS income.  Deductible and coinsurance (established by federal law)

Medicare Part C (combo deal) Voluntary  Managed care plan  Combines Parts A and B  Better benefits and lower prices than previous “Choice” plan Medicare Advantage

Medicare Part D (prescriptions) Voluntary  Premiums paid for discount drug prices  Covers only drugs on their list  Usually use generic drugs Medicare Advantage Plus Presecription

HICN  Medicare’s health insurance claim number  Nine digits with an alpha suffix  Suffix indicates how coverage was earned (i.e. suffix A is primary wage earner, suffix D is aged widow, first claimant)

Benefits  Medical Services—deductible, 20% coinsurance  Preventive—fully covered  Lab services—fully covered  Home healthcare—fully covered and 20% DME  Outpatient hospital—variable coinsurance  Blood—first 3 pints covered—20% of rest

Considered Not Medically Necessary  Routine physical exams  Dental  Eye  Hearing aid exams  Long-term care  Cosmetic surgery  Some foot care

Participating Providers  Agree to participate or opt out during enrollment periods  Must accept assignment  Cannot balance bill  File claims for patients  Learn Medicare rule (their manual is online)  Providers apply to participate

Medicare Administrative Contractors  MACs  Process Medicare claims  Act as the insurance carrier  Offer incentives to PARs

Incentives for PARs  Higher payment than for nonPAR  MAC forwards to secondary carriers  Financial incentives for  Quality reporting  E-prescriptions  Implementing an EHR  Primary care practices

Payments and Coverage  Use Medicare Fee Schedule (based on RVUs)  Mandatory ABN  Services not covered by Medicare because determined not necessary  Voluntary ABN  Services determined as excluded by Medicare Modifiers used with CPT code to show ABN was signed

NonPARs  Receive 5% less for services  Provide voluntary ABN for noncovered services  nonPAR can either accept or not accept assigment NonPAR Not Accepting Assignment  Limiting Charges  Collect no more than 115% of Medicare fee

Limiting Charge  Most a nonPAR (not accepting assignment) can collect from a Medicare patient  May have patient pay for services, then bill Medicare

Differences in Fees Collected  PAR—Medicare’s PAR standard fee (80/20)  nonPAR accepts assignment—Medicare’s nonPAR fee (5% less than PAR) (80/20)  nonPAR does not accept assignment— Medicare’s nonPAR fee (5% less than PAR)  Medicare pays 80% of nonPAR fee, patient pays difference between nonPAR fee and limiting fee

Thinking It Through 9.5 PAR Provider A. Actual fee $210 B. Medicare Fee $115 C. Medicare pays 80% $92 D. Patient pays 20% $23 E. Provider adjustment $95 ( )

Thinking It Through 9.5 nonPAR Provider accepting assignment A. Actual fee $210, Medicare Fee $115 B. Medicare nonPAR Fee $ C. Medicare pays 80% $87.40 D. Patient pays 20% $21.85 E. Provider adjustment $100.75

Thinking It Through 9.5 nonPAR Provider not accepting assignment A. Actual fee $210, Medicare Fee $115 B. Medicare nonPAR Fee $ C. Limiting Charge $ D. Patient Billed $ E. Medicare pays patient $87.40 F. Total Provider collects $ G. Patient out-of-pocket expense $38.24

Medicare Fee For Service  Choose any Medicare approved doctor  Patient is Responsible for  Annual deductible  Coinsurance  Noncovered Services  Patients receive Medicare Summary Notice (EOB)

Medicare Advantage Coordinate Care Plans  Managed care  Provide all Medicare-approved care except hospice  Capitated payments  Referrals  Patients pay deductible, copay, coinsurance

GAP Plans  Additional insurance offered by private payer  Used to fill in the “gap” and cover patient’s portions (copay, deductible, coinsurance)  Coordinate with Medicare  MACs processes claims for Medicare and sends to GAP plan

Supplemental Plan  Additional coverage to Medicare B  Usually from a previous employer (retirement benefits)  Used to pay patient’s responsibility  MAC does not coordinate with supplemental plans

Medicare Compliance  CCI (Correct Coding Initiative)  Use CPT codes and approved combinations  Approval list is updated each quarter  Use Medicare’s global periods (surgeries)  Consult Codes  Filing Timeline

Medicare’s Integrity Program  Watches for improper payments  Fraud  Abuse  Waste  Medical Review (audit system for incorrect billing)  Recovery Auditor Program (audits payments)  Zone Program Integrity Contractors (audit using data mining)

Duplicate Claims  Billing for same procedures or equipment twice  Duplicate sent if payment didn’t come  Sending same claim to more than one MAC  If payment hasn’t come, contact MAC; don’t send another claim

Incident to Billing  Services provided by someone other than the doctor (assistant or nurse)  Payment will depend on the doctor’s involvement in supervising

Roster Billing Medicare allows one bill for several patients receiving exact same tx if any of the patients on the list did not receive any other tx Immunizations is a good example

Medicare HIPAA 837P Claims  All codes listed are considered  Use a provider assignment code  Insurance type code is used when Medicare is not primary

Medicare CMS1500 Claims  Only one claim sent if there is a GAP plan  Item 19 might be used, depending on local MAC