1. Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Chapter 11 Medicare Medical Billing

2. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicare Administration  Centers for Medicare and Medicaid Services (CMS)  Purpose: To serve as a consolidated agency for Medicare and Medicaid  CMS and Social Security Administration (SSA)

3. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicare Part A Eligibility  65 or older  Adult with disability  Disabled before age of 18  Entitled individuals’ spouses  End-stage renal disease (ESRD)

4. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicare Part A Coverage  Inpatient hospital care: 90 days in a benefit period with 60-day lifetime reserve  Skilled nursing facility: 100 days during a benefit period  Home health care: Part time or intermittent skilled nursing care, home health aide, and therapies along with DME

5. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Inpatient Benefit Days  Benefit period: Time during which medical benefits are available  Basic days: First 60 days of acute inpatient care  Coinsurance days: Days after first 60 days

6. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Inpatient Benefit Days  Lifetime reserve days: Start after basic days and 30 coinsurance days in one benefit period  Skilled nursing facility days: No coinsurance for first 20 days then $124 per day for days 21 through 100 of each benefit period

7. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicare Part B Eligibility  Meet requirements for Part A  Purchase Part A  Part B purchase: Based on annual income  Meet deductible: Yearly

8. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Noncovered Services Medicare Part A and B  Routine services  Screening tests and/or screening laboratory tests  Dental care  See the full list in your student textbook, page 323.

9. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicare Providers  Part A: Hospitals, skilled nursing facilities, nursing homes, and home health and hospice agencies  Part B: Physicians, nonphysician practitioners, or suppliers who have an agreement with Medicare.

10. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicare Part C (Medicare + Choice)  Established in 1997: Same benefits as part A and B  Now Medicare Advantage Plus  Additional benefits: Hearing aids, dentures, and prescription drugs  Types of plans

11. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicare Part D  Prescription drug coverage  Eligible for Parts A and B  Premium required

12. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medigap  Authorized insurance companies  Secondary payer  Not available to HMO participants  Regulated by Medicare law  Crossover: Reassignment of coverage gap to Medigap policy

13. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medical Necessity  Procedure must match diagnosis  Nonexperimental or investigational procedures  Essential treatment  Appropriate delivery level

14. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Participating Providers  Contract with Medicare  Benefits

15. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Nonparticipating Providers  Accepting assignment –The nonparticipating provider must still file all Medicare claims on behalf of the beneficiary, accept a 5% lower fee allowance for services, understand that Medigap/supplemental insurance does not automatically cross over, and does not have access to beneficiary eligibility information.  Not accepting assignment –Payment is sent to the beneficiary.

16. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Patient’s Financial Responsibility  Par provider accepting assignment: 20% of MFS  Non-par provider accepting assignment: 20% of non-par provider’s MFS  Non-par provider not accepting assignment: Responsible for limiting charge

17. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Patient Registration  Copy the Medicare card.  Obtain patient signatures.  Determine primary and secondary payers; see the extensive list on pages 333–337 of your student textbook.

18. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicare Billing Requirements— HCPCS  Level I codes: CPT-4, procedures  Level II codes: Supplies and services and dental procedures  Level III codes: Reserved for use by regional carriers

19. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Completing Medicare Part B Claim Forms  CMS-1500 (paper)  EMC (electronic) is preferred.  Information is entered into the form locators.  All forms must be accurately completed, whether using the paper CMS-1500 or EMC using a computer, modem, and approved billing software (NSF/ANSI).

20. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Completing Medicare Part B Claim Forms  All paper forms are sent to Dallas, Texas.  Care must be taken to send the claim to the correct post office box for the region where the services were rendered

21. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicare Fraud  Definition: “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 health care benefit program”

22. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicare Fraud  Fraud scenarios: See student text pages 351–352.

23. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Other Types of Medicare fraud  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  Waiving deductibles and/or copayments without attempts to collect such monies due or when the patient is unable to pay

24. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Other Types of Medicare fraud  Falsifying information on any document filed with the government  Offering or soliciting bribes, rebates, or kickbacks

25. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicare Abuse  Definition: “Abuse may, directly or indirectly, result in unnecessary costs to the Medicare or Medicaid program, improper payment for services which [sic] fail to meet professionally recognized standards of care, or that are medically unnecessary…”  Abuse scenarios: See student textbook page 353.

26. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Protection Against Medicare Fraud and Abuse  Provider liability for fraud  Provider liability for abuse  Referring physician liability fraud/abuse  Administrative sanctions  Education and warning  Revoking assignment privileges

27. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Protection Against Medicare Fraud and Abuse  Withholding payments along with recovery of overpayments  Excluding from Medicare program  Posting provider’s name on national Sanctioned Providers list