Chapter 12 Medicare

 -  Seminars are held on Sundays from 9PM – 10PM EST  AIM- KiSweet97 during my office hours on Sunday 8PM-9PM EST or you can make an appointment. Communication with Me “Remember I am here to Help” In seminar, you can messenger me privately by clicking on my name at the left hand side of the seminar screen. I have turned off the ability for you to messenger other students privately, as that seems to be distracting. You can always other students and ask for their AIM names so that you can contact each other.

Final Project Due Unit 9  Training for Staff Members  This final project is due in Unit 9 but you will want to get started on it early so you can do a great job.  One great way to learn something new is to teach it to somebody else. Over the course of this class, you will build a PowerPoint presentation that is minimum of 27 slides outlining the major concepts every billing specialist should know.  For the Final Project due in Unit 9, you will be completing a training that outlines some basics.

Final Project (Cont’d) 1. Develop an in-service training session for new billing specialists that covers the concepts you are learning in this course; 2. You should dedicate at least 3 slides outlining these concepts: legal aspects of insurance billing, health insurance concepts, CMS-1500 forms, UB-04 forms, Blue Cross/Blue Shield, Medicare, Medicaid, and TRICARE and CHAMPVA. There should be a minimum of 27 slides. 3. Use the Note section as needed to explain terms, concepts, and definitions that you would cover if you were teaching this training  Resources that can help you:  Websites found in Extra! Extra! in each unit.  eText key terms and review questions.  This project will be due in Unit 9 and submitted to the Dropbox.

Medicare  Federal health insurance program  The largest health insurance program  Created in 1965  Managed by CMS

Medicare  Medicare Part A  Care received in hospitals and skilled nursing facilities, home and hospice care  Usually premium-free  May enroll in Medicare Part B  Medicare Part B  Physician services, outpatient hospital care, other medical services  Monthly fee or premium

Medicare  Enrollment may be automatic or by application  Low-income beneficiaries may be eligible for additional programs  QMB  SLMB  QI  Individuals enrolled receive ID cards

Medicare  The Medicare insurance program is constantly changing  Current Medicare information is available  At a local Social Security office  At the CMS web siteCMS web site  At the Medicare web siteMedicare web site

Medicare Part A  Covered services  Hospital stays  Skilled nursing facility  Home health care  Hospice care

Medicare Part A  Deductibles and copayments  Inpatient hospital care  Up to 60 days: $900 deductible  days: beneficiary pays daily copays  After 150 days: beneficiary pays all charges  Skilled nursing facility  Up to 20 days: no charges  days: beneficiary pays daily copays  After 100 days: beneficiary pays all charges

Medicare Part A  Deductibles and copays  Home health care  No deductible  Beneficiary is responsible for 20% of the Medicare approved amount for DME

Medicare Part A  Challenges  Maintaining a professional and compassionate attitude  Keeping up with changes related to covered services, deductibles, and copays

Medicare Part B  Required to pay for services and supplies which are:  Reasonable  Medically necessary  Consistent with patient’s diagnosis  Defrays cost of diagnostic, treatment, and preventative health care services

Medicare Part B  Advanced Beneficiary Notice agreements  Services the provider believes are necessary, but not covered by Medicare  ABN must be signed before the service is performed

Medicare Part B  Participating providers (PAR)  Contract with Medicare  Agree to accept Medicare approved payment rates for services  Medicare carrier remits payment to PAR  Accepts assignment for Medicare patients

Medicare Part B  Nonparticipating providers (NonPAR)  Not enrolled in the Medicare program  Can accept assignment  Subject to restrictions  Patients have higher out-of-pocket expenses  Must provide a Medicare Surgical Financial Disclosure Statement

Medicare Fee Schedule  List of Medicare approved fees for services  Based on the RBRVS system  Relative value unit  Geographic adjustment factor  National conversion factor  Calculated on an annual basis

NCCI  Financial incentive from CMS to ensure coding accuracy  Goals  To promote provider compliance with Medicare diagnosis and procedure coding guidelines  To ensure payment for provider services

NCCI  Claims are edited by an electronic screening process  Edit process verifies:  The patient is a Medicare beneficiary  All deductibles and copays have been met  Medicare is the primary payer  Diagnosis and procedure codes are correct

NCCI  NCCI edits identify:  Mutually exclusive procedures  Component part coding  Unbundling  Invalid modifiers  When errors occur, the provider is notified

Claim Submission  General information  CMS-1500 form  Filing deadline is 12/31 of the year following the date of service  All providers must submit Medicare claims for their patients  Insurance carriers for Medicare claims are selected by CMS through a bidding process

Medicare as Primary Payer  Medicare is the primary payer for nearly all provider services  Conditional primary payer status

Reinforcement Exercise  The _________________ form is used for all Medicare claims  The deadline for filing a Medicare claim is ____________________.

Supplemental Insurance  Medigap  Employer-sponsored Medicare supplemental health insurance  Medicare-Medicaid crossover program

Medicare as Secondary Payer  All primary payers must be billed before Medicare claims are submitted  Attach a copy of the primary payer’s EOB to the Medicare claim form

Other Medicare Plan Choices  Medicare Advantage Plans  Medicare Managed Care Plans  Medicare PPO  Medicare Private Fee- for-Service Plans  Medicare Specialty Plans  Medicare Savings Account Plan  Beneficiary must:  Be enrolled in Medicare Part A and B  Continue to pay the premium for Part B  Not qualify for programs related to special conditions

Processing Medicare Payments  PARs receive payments directly, on a regular basis  Payments are not claim-specific  Payment information is posted to each patient’s account

Looking Ahead  Read Chapter 13 Chapter 13 will discuss Medicaid.  Participate in Discussion In Unit 7 Discussion, you will be talking about Medicaid forms. 10 Points  Attend the Weekly Seminar or Complete Option 2 The weekly Seminar will address topics in this unit. 15 Points  Complete Unit 7 Assignment In the Unit 7 Assignment, you will be comparing Medicaid with private or commercial insurance companies. 40 Points  Complete Unit 7 Quiz This quiz will cover concepts learned in this unit. 30 Points

Questions