1. 13
Medicare Medical Billing

2. 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)

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

4. 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

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

6. 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.

7. 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.

8. Government Billing Guidelines
13.1: Discuss government billing guidelines.

9. 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.

10. 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.

11. 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.

12. 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. 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.

14. 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.

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

16. 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).

17. 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.

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

19. 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.

20. 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.

21. 13.4: Examine and complete accurate Medicare claim forms.
Medicare Claims Forms
13.4: Examine and complete accurate Medicare claim forms.

22. 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).

23. 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.

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

25. 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.

26. 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

27. 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

28. 13.5: Medicare Fraud and Abuse
Consistently using procedure/revenue codes that describe more extensive services than those actually performed

29. 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

30. 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.

31. 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.