13 Medicare Medical Billing

Key Terms and Abbreviations benefit period Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) crossover end-stage renal disease (ESRD) Electronic Remittance Advice (ERA) Healthcare Common Procedure Coding System (HCPCS)

Key Terms and Abbreviations intermediaries limiting charge Local Coverage Determinations (LCDs) Medicare abuse Medicare Advantage (MA) Medicare Administrative Contractor (MAC) Medicare fraud

Key Terms and Abbreviations Medicare Part A Medicare Part B Medicare Part D Medicare Remittance Notice (MRN) Medicare secondary payer (MSP) Medicare Summary Notice (MSN) Medigap non-par MFS

Key Terms and Abbreviations Office of Inspector General (OIG) Program of All-Inclusive Care for the Elderly (PACE) Recovery Audit Contractor (RAC) scrubbing

Chapter Objectives After completing this lecture, you should be able to complete the following learning objectives: 13.1: Discuss government billing guidelines. 13.2: Determine the amount due from the patient for a participating provider. 13.3: Understand the different Medicare fee schedules.

Chapter Objectives After completing this lecture, you should be able to complete the following learning objectives: 13.4: Examine and complete accurate Medicare claim forms. 13.5: Indentify the types of Medicare fraud and abuse that can occur.

Government Billing Guidelines 13.1: Discuss government billing guidelines.

13.1: Government Billing Guidelines Medicare Program Medicare is a federal health insurance program for those age 65 and older, people with disabilities, and individuals with end-stage renal disease (ESRD). Medicare Part A is traditional fee-for-service hospital insurance. Medicare Part B is traditional fee-for-service medical insurance.

13.1: Government Billing Guidelines Medicare Program Medicare Advantage (Medicare Part C) is a hospital and medical insurance option that offers a selection of managed care plans. Medicare Part D is prescription drug coverage.

13.1: Government Billing Guidelines Medicare Program Medicaid is a federal- and state-funded health insurance program for low-income individuals. When a person is eligible for both Medicare and Medicaid, Medicare is the primary payer.

13.1: Government Billing Guidelines Medicare Billing Requirements The Healthcare Common Procedure Coding System (HCPCS) is used to report procedures and services for Medicare patients. HCPCS Level I consists of the Current Procedural Terminology (CPT) codes.

13.1: Government Billing Guidelines Medicare Billing Requirements HCPCS Level II is used to report products, supplies, and services not included in the CPT codes. All Medicare Part B claims must be submitted electronically.

13.1: Government Billing Guidelines Medicare Billing Requirements Providers use medical billing software to create an electronic claim (electronic version of the CMS-1500 form). Electronic claims are submitted to a designated claims clearinghouse.

Amount Due 13.2: Determine the amount due from the patient for a participating provider.

13.2: Amount Due Determining Amount Due from Patient for a Participating Provider A participating Medicare Part B provider is a physician or other practitioner who contracts with Medicare to provide services for Medicare patients and to accept the Medicare fee as payment in full (accepting assignment).

13.2: Amount Due Determining Amount Due from Patient for a Participating Provider Patients with traditional Medicare Part B coverage (fee-for-service) are responsible for 20% of the Medicare Fee Schedule after the deductible has been met.

Medicare Fee Schedules 13.3: Understand the different Medicare fee schedules.

13.3: Medicare Fee Schedules Fee Schedules for Participating and Non-Participating (Non-Par) Providers The Medicaid Fee Schedule (MFS) applies to services provided by participating providers who accept assignment.

13.3: Medicare Fee Schedules Fee Schedules for Participating and Non-Participating (Non-Par) Providers Participating providers are reimbursed at rates 5% higher than non-participating providers. The non-par MFS provides a 5% lower reimbursement for nonparticipating providers who accept assignment.

13.4: Examine and complete accurate Medicare claim forms. Medicare Claims Forms 13.4: Examine and complete accurate Medicare claim forms.

13.4: Medicare Claims Forms Completing and Filing Claims Electronic versions of the CMS-1500 form for medical services and the UB-40 form for hospital services are submitted for Medicare claims. The same criteria as in non-Medicare claims applies for required information in each of the form locators (fields).

13.4: Medicare Claims Forms Completing and Filing Claims In some cases, there may be special requirements for how certain fields are used in filing Medicare claims. Medical office specialists should be familiar with Medicare contractor (carrier) rules and regulations to ensure accuracy in creating and submitting claims.

Medicare Fraud and Abuse 13.5: Indentify the types of Medicare fraud and abuse that can occur.

13.5: Medicare Fraud and Abuse Medicare fraud is defined by CMS as knowingly and willfully executing or attempting to execute a scheme or artifice to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any healthcare benefit program.

13.5: Medicare Fraud and Abuse Most common types of Medicare fraud: Billing for services that were not rendered Misrepresenting as medically necessary any non-covered or screening services by reporting covered procedure/revenue codes

13.5: Medicare Fraud and Abuse Most common types of Medicare fraud: Signing blank records or certification forms or falsifying information on records or certification forms for the sole purpose of obtaining payment

13.5: Medicare Fraud and Abuse Consistently using procedure/revenue codes that describe more extensive services than those actually performed

13.5: Medicare Fraud and Abuse Other types of fraud include: Using an incorrect or invalid provider number Selling or sharing Medicare claim numbers Offering or accepting bribes, rebates, or kickbacks

13.5: Medicare Fraud and Abuse Medicare Abuse Medicare abuse is defined by CMS as actions that result in payment for items or services when there is no legal entitlement to that payment. Abuse occurs when the provider has not knowingly or intentionally misrepresented the facts to obtain payment.

13.5: Medicare Fraud and Abuse Medicare Abuse The two most common types of abuse are billing for services in excess of those needed by the patient and routinely filing duplicate claims.