Medicare 101

1. Medicare 101 Part 1: Introduction to Medicare Part B Provider Outreach & Education – January 8, 2014

2. Disclaimer This resource is not a legal document. This presentation was prepared as a tool to assist our providers. This presentation was current at the time it was created. Although, every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Reproduction of this material for profit is prohibited. 

3. Agenda • Medicare Basics • Types of Medicare • Part B Providers • Part B Helpful Hints • Medicare Appeals • Cahaba GBA Website Self-Service Tools • Online Polling

4. Medicare Basics

5. Inception of Medicare 1965 – Medicare signed into law by President Lyndon B. Johnson

6. Key Medicare Administrators • Congress • Department of Health and Human Services (HHS) • Social Security Administration (SSA) • Centers for Medicare and Medicaid Services (CMS) • Office of the Inspector General (OIG)

7. Medicare Contractors • Medicare Administrative Contractor (MAC) • Beneficiary Contact Center (BCC) • Coordinator of Benefits Contractor (COBC) • Medicare Secondary Pay Recovery Contractor (MSPRC) • Comprehensive Error Rate Testing (CERT) • Recovery Auditor (RA) • Zone Program Integrity Contractor (ZPIC)

8. Medicare Eligibility Requirements

9. 65 Beneficiary Eligibility based on: 65 years or older Individual/Spouse/Parent Work a minimum of 10 years Contributions to FICA US Citizen or Permanent Legal Resident

10. Disability Beneficiary Eligibility based on: Under the age of 65 Beneficiary is entitled to Social Security disability benefits for 24 months Beneficiary received a disability pension from the railroad retirement board and meet certain conditions Beneficiary receives Social Security disability benefits because of Lou Gehrig’s disease (amyotrophic lateral sclerosis) Beneficiary worked long enough in a government job where Medicare taxes were paid and is entitled to Social Security disability benefits for 24 months

11. End Stage Renal Disease (ESRD) Beneficiary Eligibility based on: Any Age Diagnosed with ESRD: Receiving Dialysis Kidney Transplant Recipient http://cms.gov/Center/Special-Topic/End-Stage-Renal-Disease-ESRD-Center.html?redirect=/center/esrd.asp

12. Identifying the Medicare Beneficiary Red, White, and Blue Card Name Health Insurance Claim Number (HICN) Sex Type of Entitlement Effective Date

13. Medicare Beneficiary Identification Tips Ask patients for insurance cards instead of Medicare Card Recommend making copies of all insurance cards presented Update patient information annually, preferably after open enrollment ends Check the effective dates on the coverage types, they are not always the same Enter the patients name exactly on the claim as it appears on the patients Medicare card

14. Types of Medicare

15. Part A Covers: Inpatient Care in Hospitals Inpatient Care in a Skilled Nursing Facility Hospice Home Health Services Inpatient Care in a Religious Nonmedical Healthcare Institution

16. Part B Covers: Physicians Services Outpatient Care Durable Medical Equipment Other Medical Services

17. Part C Offers: Part A & B Coverage Combination May offer extra coverage Most included Medicare Prescription drug coverage Claims are processed by private insurance companies http://www.cms.gov/transmittals/downloads/R97MCM.pdf

18. Part D Available: To anyone who is eligible for Medicare Part A or B Provided through: Prescription Drug Plans Other Medicare Health Plans Retiree Employers and Union Plans

19. Part B Providers

20. Eligible Part B Providers

21. Provider Enrollment Paper Applications: CMS 855B--Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers CMS 855I --Medicare Enrollment Application for Physicians and Non-Physician Practitioners CMS 855R--Medicare Enrollment Application for Reassignment of Medicare Benefits CMS 855O--Medicare Enrollment Application for Eligible Ordering and Referring Physicians and Non-physician Practitioners CMS 855S--Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications.html

22. Provider Enrollment Online Provider Enrollment Provider Enrollment, Chain, and Ownership System (PECOS) allows: New/Revalidation/Update Enrollment Applications Submit Related Documentation Electronic Signatures https://pecos.cms.hhs.gov

23. Provider Enrollment Electronic Funds Transfer (EFT) Authorization Agreement CMS 588 Form Signature required by authorized official Providers initially enrolling in the Medicare program Providers enrolled in Medicare but not receiving EFT payments and making changes in your enrollment Revalidation -providers and suppliers that were enrolled prior to March 25, 2011 http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS588.pdf

24. Provider Participation Participating Non-Participating Does not agree to accept assignment of Medicare benefits Payment is made to the Medicare beneficiary Allowable based on five percent less of Physician Fee Schedule Cannot charge patient more than the 115% limiting charge Medigap is not auto crossover Can accept assignment on case by case but allowed non-participating allowable • Agrees to accept assignment of Medicare benefits • Will accept Medicare’s allowable in full • Payment is made to the provider • Collects deductible, co-insurance and excluded services from patient • Allowance five percent higher of Physician Fee Schedule • Included in Medpard directory • Automatic Medigap crossover

25. Medicare Physician Fee Schedule Used by physicians and non-physician practitioners Pays 80% of the allowed amount for most services Other fee schedules include: Ambulance Clinical Lab Ambulatory Surgical Center Drugs and Biologicals http://www.cahabagba.com/part-b/claims-2/fee-schedules/2014-fee-schedules/

26. Medicare Physician Fee Schedule http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html/

27. Medicare Physician Fee Schedule CMS Searchable Physician Fee Schedule http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

28. Part B helpful Hints

29. 2014 Medicare Part B Rates 2014 Part B Deductible: $147.00 2014 Therapy Cap: $1920.00 Therapy Cap includes: physical therapy and speech-language pathology combined and for occupational therapy

30. Contacting Cahaba GBA Interactive Voice Response System Claim Status Eligibility information Order Remittance Advice Unlimited Check Amounts Provider Authentication Contractor/Carrier assigned Provider Transaction Access Number (PTAN) National Provider Identifier (NPI) Last five digits of your Tax Identification Number 1-877-567-7271 http://www.cahabagba.com/contact-us/

31. Provider Call Tips Have your provider information, be ready to provide the physician’s PTAN/NPI/Last 5 Digits of Tax ID Beneficiary Information as listed on the Medicare Card, Health Information Number and Exact Name If calling concerning a claim denial, be ready to provide the reason for the denial as listed on the Remittance Advice If calling concerning a claims denial, be ready to provide the dollar amount of the claims billed If calling concerning a particular payment, be ready to provide the Remittance Advice Number Request your call reference number Example: GINQ-0000000

32. Railroad Medicare Railroad Medicare Claims & Inquiries contact: Palmetto GBA IVR 877-288-7600 PCC 888-355-9165

33. DMEPOS Jurisdiction C Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Claims & Inquiries contact: CGS IVR 866-238-9650 CSR 866-270-4909

34. Home Health & Hospice Jurisdiction C Home Health & Hospice Claims & Inquiries contact: Palmetto GBA IVR 866-238-9650 CSR 866-270-4909

35. Medicare Appeals

36. Medicare Appeal Levels 60 Days To File $1430 AIC *AIC – Amount in Controversy

37. Redetermination Submission Paper – CMS20027 Form Fax – Redetermination Smart Form http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms20027.pdf http://www.cahabagba.com/documents/2012/02/part-b-redetermination_request_b.pdf

38. Cahaba GBA Website

39. Cahaba GBA Website http://www.cahabagba.com/

40. Claims Issue Log http://www.cahabagba.com/part-b/claims-2/claims-issue-log/

41. Claims Submission Errors http://www.cahabagba.com/part-b/claims-2/claims-submission-issues-and-tips-to-prevent-denials/

42. Provider Education http://www.cahabagba.com/part-b/education/

43. Calendar of Events https://apps.cahabagba.com/apps/course_registration/al/calendar.jsp

44. FORESEE Survey

45. Online Polling

46. Live ~ Post Presentation Polling

47. resources

48. Resources Cahaba GBA Website https://www.cahabagba.com/ Centers for Medicare and Medicaid Services http://www.cms.gov/

49. Questions? Provider Contact Center   1 (877) 567-7271

50. Thank you for Joining Us!Participants can obtain the evaluation via one of the following options:1. Upon the conclusion of the event, the evaluation will be launched2. You may copy and paste the electronic evaluation link: http://listmgr.cahabagba.com/subscribe/survey?f=1517 to your browser and complete the survey. We appreciate your feedback and comments