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Chapter 9 Medicare
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Medicare Federal program Managed by CMS under DHHS
Primarily for retired over 65 Who pays for Medicare?
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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
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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
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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)
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Medicare Part C (combo deal) Voluntary
Managed care plan Combines Parts A and B Better benefits and lower prices than previous “Choice” plan
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Medicare Part D (prescriptions) Voluntary
Premiums paid for discount drug prices Covers only drugs on their list Usually use generic drugs
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HCIN Medicare’s health insurance claim number
Nine digits with an alpha suffix Suffix indicates how coverage was earned
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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
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Considered Not Medically Necessary
Routine physical exams Dental Eye Hearing aid exams Long-term care Cosmetic surgery Some foot care
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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
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Medicare Administrative Contractors
MACs Process Medicare claims Act as the insurance carrier Offer incentives to PARs
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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
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Modifiers used with CPT code to show ABN was signed
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
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NonPARs Paid 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
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Limiting Charge Most a nonPAR (not accepting assignment) can charge a Medicare patient May have patient pay for services, then bill Medicare
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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
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Thinking It Through 9.5
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Medicare Fee For Service
Choose any Medicare approved doctor Responsible for Annual deductible Coinsurance Noncovered Services Patients receive Medicare Summary Notice (EOB)
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Medicare Advantage Managed care
Provide all Medicare-approved care except hospice Capitated payments Referrals Patients pay deductible, copay, coinsurance
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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
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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
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Medicare Compliance CCI (Correct Coding Initiative) Consult Codes
Use CPT codes and approved combinations Approval list is updated each quarter Use Medicare’s global periods (surgeries) Consult Codes Filing Timeline
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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)
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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
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Incident to Billing Services provided by someone other than the doctor (assistant or nurse) Payment will depend on the doctor’s involvement in supervising
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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
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Medicare HIPAA 837P Claims
All codes listed are considered Use a provider assignment code Insurance type code is used when Medicare is not primary
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Medicare CMS1500 Claims Only one claim sent if there is a GAP plan
Item 19 might be used, depending on local MAC
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