1. © 2009 Cengage Learning. All Rights Reserved. Medicare

2. © 2009 Cengage Learning. All Rights Reserved. Agenda  Medicare coverage and eligibility  Certification  Payment  Appeals

3. © 2009 Cengage Learning. All Rights Reserved. Medicare Coverage and Eligibility  Part A Hospital Services Coverage  SNF, HHA, hospice Eligibility  Over age 65 and eligible for SSA  Some disabled Funding  Payroll taxes

4. © 2009 Cengage Learning. All Rights Reserved. Medicare Coverage and Eligibility  Part B Physician Services Coverage  Supplementary medical insurance  Eligibility Eligible for Part A and enrolled in Part B Medicare Advantage beneficiaries  Funding Premiums and co-payments

5. © 2009 Cengage Learning. All Rights Reserved. Medicare Coverage and Eligibility  Part C Medicare Advantage Coverage  Parts A, B, and D  May have supplemental benefits or discounts Eligibility  Eligible for Part A and enrolled in Part B Funding  Trust fund  May have premiums or co-pays

6. © 2009 Cengage Learning. All Rights Reserved. Medicare Coverage and Eligibility  Part D Prescription Drugs Coverage  Prescription drugs Eligibility  Eligible for Part A and enrolled in Part B  Medicare Advantage beneficiaries (Part C) Funding  Supplementary Medical Insurance Trust Fund  Premiums or co-payments

7. © 2009 Cengage Learning. All Rights Reserved. Miscellaneous Medicare Provisions  Low Income Assistance  Secondary payor rule  Medigap  National Coverage Decisions  Advance Beneficiary Notice

8. © 2009 Cengage Learning. All Rights Reserved. Certification  Conditions of Participation Providers Physicians and Suppliers Medicare Advantage Prescription Drug Providers

9. © 2009 Cengage Learning. All Rights Reserved. Medicare Payment  Reimbursement Methodology Prospective Payment System (PPS) Diagnostic Related Groups (DRG) Special Adjustments  Low income patients  Medical education programs  Outliers

10. © 2009 Cengage Learning. All Rights Reserved. Medicare Payment  Reimbursement for Physicians Resource Based Relative Value Scale (RBRVS) HCFA Common Procedural Coding System (HCPCS) Capitation Market-Based System Assignment and Reassignment

11. © 2009 Cengage Learning. All Rights Reserved. Medicare Appeals  Appeals by Providers, Physicians, and Other Suppliers for Parts A and B  Appeals by Beneficiaries for Parts C and D