Medical Coding & Insurance Unit 8 Seminar

CMS Centers for Medicare and Medicaid Services (CMS) Centers for Medicare and Medicaid Services (CMS) Purpose: To serve as a consolidated agency for Medicare and Medicaid Purpose: To serve as a consolidated agency for Medicare and Medicaid CMS and Social Security Administration (SSA) CMS and Social Security Administration (SSA)

Medicare Part A Medicare Part A Eligibility Eligibility –65 or older –Adult with disability –Disabled before age of 18 –Entitled individuals’ spouses –End-stage renal disease (ESRD) Coverage Coverage –Inpatient – 90 days per benefit period, coinsurance after 60 days –SNF – 100 days per benefit period, coinsurance after 20 days –Home health care

Medicare Part B Eligibility Eligibility –Meet requirements for Part A –Purchase Part A –Part B purchase: Based on annual income –Meet deductible: Yearly

Non Covered Services Routine services Routine services Screening tests and/or screening laboratory tests Screening tests and/or screening laboratory tests Dental care Dental care Routine eye care Routine eye care Yearly physical exams Yearly physical exams Vaccinations Vaccinations Long term care Long term care Treatment outside of the US Treatment outside of the US Prescription drugs Prescription drugs See the full list in your student textbook, page 323. See the full list in your student textbook, page 323.

Medicare Part C Same benefits as Medicare Part A and B Same benefits as Medicare Part A and B Additional benefits: Additional benefits: –Hearing aids –Dentures –Prescription drugs

Medicare Part D Medicare Part D Prescription drug coverage Prescription drug coverage Eligible for Parts A and B Eligible for Parts A and B Premium required Premium required

Participation VS. Non Participating Participation VS. Non Participating Participating: Participating: –Contracted –Paid directly by Medicare Non Participating: Non Participating: –Must file to Medicare –Must have an AOB to get paid directly –5% reduction in reimbursement

Medicare Fraud Using an incorrect or invalid provider number in order to be paid at a higher rate Using an incorrect or invalid provider number in order to be paid at a higher rate Selling or sharing Medicare claim numbers in order to facilitate the filing of false claims Selling or sharing Medicare claim numbers in order to facilitate the filing of false claims Waiving deductibles and/or copayments without attempts to collect such monies due or when the patient is unable to pay Waiving deductibles and/or copayments without attempts to collect such monies due or when the patient is unable to pay Falsifying information on any document filed with the government Falsifying information on any document filed with the government Offering or soliciting bribes, rebates, or kickbacks Offering or soliciting bribes, rebates, or kickbacks

Charged with Fraud or Abuse Withholding payments along with recovery of overpayments Withholding payments along with recovery of overpayments Excluding from Medicare program Excluding from Medicare program Posting provider’s name on national Sanctioned Providers list Posting provider’s name on national Sanctioned Providers list

Medicaid State regulated State regulated Pregnant women and children under 6 who are 133% below poverty level Pregnant women and children under 6 who are 133% below poverty level Children 6-19 with family income level up to 100% of poverty rate Children 6-19 with family income level up to 100% of poverty rate SSI recipients SSI recipients Living in medical institution with income level up to 300% of SSI standard Living in medical institution with income level up to 300% of SSI standard Medically needy Medically needy

Federally Mandated Services Inpatient / Outpatient services Inpatient / Outpatient services Prenatal care Prenatal care Vaccines for children Vaccines for children Nursing facility services for persons 21 years of age and older Nursing facility services for persons 21 years of age and older Family planning Family planning Lab & X-ray services Lab & X-ray services Home health Home health

Medicaid Billing Verification Verification –Always verify patient status prior to seeing the physician –Some electronic verification available –Check for restricted status, which requires the patient to see a specific physician (e.g., PCP) and/or pharmacy. Time limits Time limits –95 day to file claim & 180 days to appeal Newborn claims Newborn claims –Boy / Girl then mothers name

Tricare Eligibility Eligibility Sponsor: Member of military Sponsor: Member of military Beneficiary: Family members of member of military Beneficiary: Family members of member of military Service/military retiree: Retired military service member Service/military retiree: Retired military service member A military retiree may remain in TRICARE until age 65 A military retiree may remain in TRICARE until age 65 CHAMPVA beneficiaries are not eligible for TRICARE CHAMPVA beneficiaries are not eligible for TRICARE

CHAMPVA Administered by the Department of Veterans Affairs Administered by the Department of Veterans Affairs Veterans with 100% service-related disabilities Veterans with 100% service-related disabilities Spouse is eligible Spouse is eligible All services must be approved All services must be approved Last payer after all insurance and Medicare Last payer after all insurance and Medicare

Any Questions? Any Questions? Good Night Good Night & Thank you Thank you