Medicare Claims UBO Programs and Compliance Analyst, Finance and Accounting Division, US Army Medical Command 24 and 26 February 2015 For entry into the webinar, log in to: Enter as a guest with your full name and Service or NCR MD affiliation for attendance verification. Instructions for CEU credit are at the end of this presentation. View and listen to the webinar through your computer or Web–enabled mobile device. Note: The DHA UBO Program Office is not responsible for and does not reimburse any airtime, data, roaming or other charges for mobile, wireless and any other internet connections and use. If you need technical assistance with this webinar, contact us at You may submit a question or request technical assistance at any during a live broadcast time by entering it into the “Question” field of Adobe Connect.

Overview Applicable Laws, Regulations, and Guidance Identification of Medicare Eligible Patients Cost Recovery Options 2

Applicable Laws, Regulations, Guidance 10 USC 1079b(a): The Secretary of Defense shall implement procedures under which a military medical treatment facility may charge civilians who are not covered beneficiaries (or their insurers) fees representing the costs, as determined by the Secretary of trauma, and other medical care provided to such civilians. 32 CFR 220.1: Codifies 10 USC 1079b, establishes the statutory obligation of civilian non-beneficiary patients to reimburse the United States the reasonable charges for healthcare services provided to them. 42 CFR 482 – Conditions of Participation For Hospitals. – § 482.2: Provisions of emergency services by nonparticipating hospitals. 3

Applicable Laws, Regulations, Guidance Medicare Benefits Manual – Chapter 16 – General Exclusions From Coverage Items and Services Furnished by Federal Provider of Services or Federal Agency – Generally, Federal providers are excluded from participation in the Medicare program. However, Federal hospitals, like other nonparticipating hospitals, may be paid for emergency inpatient and outpatient hospital services. Medicare Claims Processing Manual – Chapter 3 – Inpatient Hospital Billing Payment for Services Received in Nonparticipating Providers – A. Hospital Filed Claims – B. [Medicare] Beneficiary Filed Claim Defense Health Agency (DHA) Uniform Business Office (UBO) User Guide, current edition. 4

Identification of Medicare Eligible Patients DD Form 2569 – Item 11 – Medicare or Medicaid Information – Item 12. Certification, Release and Assignment Item 12c: NON-DoD PATIENTS: I authorize and request that the proceeds of any and all benefits be paid directly to the MTF for healthcare services provided me and/or my minor dependents. ACKNOWLEDGEMENT: I hereby agree to pay for any service not covered in whole or in part by my third-party insurer. Item 12d: NON-DoD MEDICARE PATIENTS: I acknowledge I am responsible for full payment of any services not covered by Medicare, including but not limited to patient copayments and deductibles. Ensure DD Form 2569 is signed in items 13a or 14a. 5

Identification of Medicare Eligible Patients Example of DD Form

Identification of Medicare Eligible Patients Medicare Coverage Card: – Original Medicare Parts A and B: Red, White and Blue Card – Medicare Advantage Part C: Health Benefits Card issued by the Insurer: 7

Identification of Medicare Eligible Patients Patient Category - K93 MEDICARE - CIVILIAN EMERGENCY – Currently set to bill the Agency at the Interagency Rate. Problem: No paid mode – charges do not generate. Long-Term Solution: PATCAT Table update will change to bill the Individual at the Full Reimbursement Rate. Short-term Solution: Use Patient Category – K92 A CIVILIAN EMERGENCY CARE. – Set to bill the Individual at the Full Reimbursement Rate. – An account and charges will generate at the Full Reimbursement Rate. – Manually calculate Interagency Rate if you choose to bill Medicare. We are allowed to: – Bill non-beneficiary Medicare Enrolled Patients directly. – Bill Medicare as a Non-Participating Provider. 8

What Restrictions or Limitations do I need to be aware of? – Medicare will only accept claims from Federal Hospital that are in the following locations considered to be within the U.S.: The 50 States; The District of Columbia; The Commonwealth of Puerto Rico; The Virgin Islands; Guam; The Commonwealth of the Northern Mariana Islands; American Samoa; and Territorial waters adjoining the land areas of the U.S. for services furnished on board a ship. – A hospital is considered outside the U.S. if it is not physically located in one of the locations just mentioned, even if it is owned or operated by the U.S. Government. Care provided in any of the DoD Hospitals overseas to Medicare Enrolled Patients will not be covered by Medicare, therefore patient is responsible for payment of their medical care. Cost Recovery Options 9

What Restrictions or Limitations do I need to be aware of ? (cont.) – Non-Participating Providers choosing to bill Medicare must submit an election to bill statement to Medicare each calendar year to receive direct payment from Medicare for all claims filed that year. The statement of election to bill Medicare is submitted to the Medicare Administrative Contractor (MAC) for your jurisdiction. The statement must be received by the MAC by December 31 st each calendar year. Determining your MAC will be covered on slide 14. – Non-Participating Providers may not bill any Medicare beneficiary beyond deductibles, coinsurance, and non-covered services in that calendar year. – Non-Participating Providers may not file an election for the calendar year if it has already charged any Medicare beneficiary for covered services furnished in that year. Cost Recovery Options 10

What Restrictions or Limitations do I need to be aware of? (cont.) – Medicare has not issued an Election to Bill Medicare statement template. – The following is the information Medicare requires in the Election to Bill Statement: DoD Hospital elects to claim payment under the Medicare program. DoD Hospital understands that payment for emergency services can be made to a non-participating hospital only if the hospital elects to receive reimbursement from Medicare for all emergency services furnished to Medicare beneficiaries in a calendar year. DoD Hospital understands that an election to bill cannot be withdrawn during the year. Statement is signed by an authorized official of the DoD Hospital. – Further information concerning billing election can be found in the Medicare Claims Processing Manual , Chapter 3, Section 120. Cost Recovery Options 11

What medical care/services are payable by Medicare? – Federal Non-Participating Hospital or Beneficiary Filed Claim: Emergency Inpatient Hospital, Emergency Outpatient Hospital, Some Part B medical and other health services may be covered and paid on a non-emergency basis, for example: – Laboratory tests and X-rays, – Ambulance services, – Durable medical equipment. Cost Recovery Options 12

What form is used to bill Medicare or the Patient? –Use the UB-04 or it’s electronic equivalent to bill Medicare. In Field Locator 80 Remarks enter: “Federal Hospital filed emergency admission”. Send medical records with UB-04/electronic equivalent to substantiate the emergency. –Use an Invoice and Receipt (I&R) to bill the Patient. The patient will use the CMS 1490S to submit the I&R to Medicare. If the I&R is not sufficiently itemized, the patient is entitled to request from the hospital an itemized statement. What billing rate should be used? –When billing Medicare you would use the Interagency Rate. –When billing the Patient you would use the Full Reimbursement Rate. Cost Recovery Options 13

Where do I send Medicare claims? – The Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003 mandated that the Secretary of Health & Human Services replace Part A (Hospital) Fiscal Intermediaries and Part B (Medical) Carriers with Medicare Administrative Contractors (MACs). – To determine the MAC for your state or jurisdiction go to: Systems/Monitoring-Programs/Medicare-FFS-Compliance- Programs/Review-Contractor-Directory-Interactive-Map/index.html Systems/Monitoring-Programs/Medicare-FFS-Compliance- Programs/Review-Contractor-Directory-Interactive-Map/index.html Cost Recovery Options 14

Is there a deadline for filing claims to Medicare? – Claims must be filed to the appropriate MAC no later than 12 months or one calendar year from the date of services (DOS). Is there a deadline for billing the Patient? – There is no time limit for billing the Patient, however to enable the patient to submit their bill to Medicare, the patient should be billed within the Medicare Filing Deadline. Cost Recovery Options 15

How much will Medicare reimburse a Federal Non-Participating Hospital? – Emergency Inpatient Claims: Payment to Federal hospitals will be based on the lower of the actual charges from the hospital or rates published for Federal hospitals in the “Federal Register” under Office of Management and Budget - Cost of Hospital and Medical Care and Treatment Furnished by the United States; Certain Rates Regarding Recovery from Tortiously Liable Third Persons.“ Cost Recovery Options 16

How much will Medicare reimburse a Federal Non-Participating Hospital? – Emergency Outpatient Claims: Eighty-five percent of the total covered charges is the estimated cost figure. The applicable Part B deductible is subtracted. Coinsurance is subtracted from the remainder. Subtracting the deductible from 85 percent of the total covered charges and applying the 20 percent coinsurance rate to the remainder obtains the patient’s coinsurance amount. The hospital will be paid cost (85 percent of covered charges) minus deductible and coinsurance. – Part B Medical and Other Health Services Part B medical and other health services, including hospital-based ambulance services may be covered and paid on a non-emergency basis. To calculate the amount paid by Medicare, the hospital subtracts the Part B deductible from the total covered charges and applies the 80 percent payment rate. Cost Recovery Options 17

Cost Recovery Options How are unpaid balances resolved? –Medicare: Cannot bill the patient for difference between amount allowed and amount billed. Amount determined to be the patient’s responsibility as listed on the Medicare Remittance Advices (MRA) can be billed and recovered from the patient. Only unpaid amounts due from the patient can be transferred to DFAS/Treasury. Contact your Service Program Manager for instructions on uncollectible debit resolution process. –Patient: Any unpaid balance can be transferred to DFAS/Treasury. 18

Summary Summary: – Be familiar with the laws and regulations governing Federal Non- Participating Hospitals billing Medicare and Medicare Patients. – Be familiar with how to identify a Medicare Enrolled Patient. – Be familiar with the cost recovery options for medical care provided to civilian emergency Medicare enrolled patients. 19

Thank You Questions? 20

Instructions for CEU Credit This in-service webinar has been approved by the American Academy of Professional Coders (AAPC) for 1.0 Continuing Education Unit (CEU) credit for DoD personnel (.mil address required). Granting of this approval in no way constitutes endorsement by the AAPC of the program, content or the program sponsor. There is no charge for this credit. Live broadcast webinar (post-test not required) – View the entire Live broadcast – Complete the anonymous survey at the end of the broadcast, entering your military address when prompted. – After completion of both of the live broadcasts and after attendance records have been verified, a Certificate of Approval including an AAPC Index Number will be sent via to participants who completed the survey as required. This may take several business days. Archived webinar (post-test required) – View the entire archived webinar (free and available on demand at – Complete a post-test available within the archived webinar – answers to – If you receive a passing score of at least 70%, we will MHS personnel with a.mil address a Certificate of Approval including an AAPC Index Number The original Certificate of Approval may not be altered except to add the participant’s name and webinar date or the date the archived Webinar was viewed. Certificates should be maintained on file for at least six months beyond your renewal date in the event you are selected for CEU verification by AAPC For additional information or questions regarding AAPC CEUs, please contact the AAPC. Other organizations, such as American Health Information Management Association (AHIMA), American College of Healthcare Executives (ACHE), and American Association of Healthcare Administrative Managers (AAHAM), may also grant credit for DHA UBO Webinars. Check with the organization directly for qualification and reporting guidance. 21