1. Medicare Chapter 12 Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

2. 2 Policies and Regulations  Centers for Medicare and Medicaid Services (CMS) Divisions  Center for Medicare Management  Center for Beneficiary Choices  Center for Medicaid and State Operations

3. 3Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Eligibility Requirements  People 65+ who are retired on Social Security  People 65+ who are retired from railroad or civil service  Disabled  Children and adults with kidney disease  Kidney donors

4. 4Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Health Insurance Card

5. 5Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Medicare Part A: Hospital Benefits  hospital up to 90 days  nursing facility up to 100 days  home healthcare services  psychiatric hospital  hospice care  respite care

6. 6Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Medicare Part B: Medical Benefits  medical expenses  clinical laboratory services  home health care  outpatient hospital care  blood

7. 7Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Medicare Part C: Medicare Advantage Plan  Available plans:  HMO  POS  PPO  PFFS  PSO  RFBS  MSA (pilot)

8. 8Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Medicare Part D  Prescription drug benefit  Effective January 1, 2006  Eligible Medicare/Medicaid member pays no premium or deductible  Tiered drug plan  Check Medicare information for authorization requirements

9. 9Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Railroad Retirement Benefits  Medical insurance premiums automatically deducted  Entitled to benefits for covered services at a qualified American facility  Some may be member of  Railroad hospital association  Prepayment plans  Contracts with Medicare

10. 10Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Employed Elderly Benefits  Federal laws and regulations:  Omnibus Budget Reconciliation Act (OBRA)  Tax Equity and Fiscal Responsibility Act (TEFRA)  Deficit Reduction Act (DEFRA)  Consolidated Omnibus Budget Reconciliation Act (COBRA)  Tax Reform Act

11. 11Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Determining if Medicare is Primary or Secondary  Ask about other insurance.  Copy Medicare card.  Ask about supplemental coverage.  Call the carrier.  Bill correctly.

12. 12Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Medicare Managed Care Plans  Health Maintenance Organizations  risk plan  cost plan  noncontract physician  Carrier dealing prepayment organization

13. 13Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Utilization and Quality Control  Quality Improvement Organization (QIO)  Federal False Claims Amendment Act  Clinical Laboratory Improvement Amendment (CLIA)

14. 14Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. HIPAA Compliance Alert  Some Medicare billing compliance issues include:  Reassignment of payment  Correct procedure code assignment and service utilization  Accurate diagnostic code assignment  Documentation related to selection of procedural codes for services performed  Correct coding initiative edits

15. 15Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Payment Fundamentals  par/nonpar  limiting charge  prior authorization  waiver of liability provision  elective surgery estimate  prepayment screens  Correct Coding Intiative

16. 16Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Medicare Reimbursement  chronology of Prospective Payment System (PPS)  reasonable fee  resource-based relative value scale  Healthcare Common Procedure Coding System (HCPCS)  Physician Quality Reporting Initiative (PQRI)

17. 17Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Medicare Reimbursement (cont’d.)  RBRVS Formula: RVU x GAF x CF = Medicare $ per service

18. 18Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Claim Submission  local coverage determination  MACs and FIs  provider identification numbers  patient’s signature authorization  time limit – 1 year from date of service  paper/electronic claims

19. 19Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Provider Identification Numbers  PINs  UPINs  PPINs  NPI  DME  EIN

20. 20Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Claim Submission (cont’d)  Medicare/Medicaid claims  Medicare/Medigap claims  Medicare/Employer supplemental insurance claims  Medicare/Supplemental and MSP claims  claims for deceased patients  physician substitute coverage – modifiers  –Q5 and –Q6

21. 21Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. After Claim Submission  remittance advice (RA)  Medicare summary notice (MSN)  posting payments  review and redetermination process

22. 22Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Medicare Overpayments  charges processed more than once  duplicate payments from Medicare and secondary payer  physician is paid directly, unassigned  error