1 / 23

Medicare

10. Medicare. 10-2. Learning Outcomes. When you finish this chapter, you will be able to: 10.1 List the eligibility requirements for Medicare program coverage. 10.2 Describe the coverage provided by Medicare Part A, Part B, Part C, and Part D.

satin
Download Presentation

Medicare

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 10 Medicare

  2. 10-2 Learning Outcomes When you finish this chapter, you will be able to: 10.1 List the eligibility requirements for Medicare program coverage. 10.2 Describe the coverage provided by Medicare Part A, Part B, Part C, and Part D. 10.3 Describe medical and preventive services that are covered or excluded under Medicare Part B. 10.4 Review the billing rules governing Medicare participating providers. 10.5 Explain the calculations used to determine nonparticipating provider payments for assigned and unassigned claims under Medicare.

  3. 10-3 Learning Outcomes (Continued) When you finish this chapter, you will be able to: 10.6 Outline the features of the Original Medicare Plan. 10.7 Discuss the features and coverage offered under Medicare Advantage plans. 10.8 Explain the coverage that Medigap plans offer. 10.9 Compare the Medicare PQRI, Medical Review (MR), and RAC programs. 10.10 Demonstrate the ability to prepare correct Medicare primary claims.

  4. 10-4 Key Terms • advance beneficiary notice of noncoverage (ABN) • carrier • Clinical Laboratory Improvement Amendments (CLIA) • Common Working File (CWF) • fiscal intermediary • Health Professional Shortage Area (HPSA) • incident-to services • initial preventive physical examination (IPPE) • limiting charge • local coverage determination (LCD) • Medical Review (MR) Program • Medical Savings Account (MSA) • Medicare administrative contractor (MAC)

  5. 10-5 Key Terms (Continued) • Medicare Advantage • Medicare card • Medicare health insurance claim number (HICN) • Medicare Modernization Act (MMA) • Medicare Part A (Hospital Insurance [HI]) • Medicare Part B (Supplementary Medical Insurance [SMI]) • Medicare Part C • Medicare Part D • Medicare Summary Notice (MSN) • Medigap • national coverage determination (NCD) • notifier • Original Medicare Plan • Quality Improvement Organization (QIO)

  6. 10-6 Key Terms (Continued) • Physician Quality Reporting Initiative (PQRI) • roster billing • screening service • urgently needed care • waived tests

  7. 10-7 10.1 Eligibility for Medicare • Individuals eligible for Medicare are in one of six categories: • Age sixty-five or older • Disabled adults • Disabled before age eighteen • Spouses of deceased, disabled, or retired employees • Retired federal employees enrolled in the Civil Service Retirement System (CSRS) • Individuals of any age diagnosed with end-stage renal disease (ESRD)

  8. 10-8 10.2 The Medicare Program • Medicare Part A(Hospital Insurance [HI])—program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care • Medicare Part B(Supplementary Medical Insurance [SMI])—program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies

  9. 10-9 10.2 The Medicare Program (Continued) • Medicare Part C—managed care health plans under the Medicare Advantage program • Medicare Modernization Act (MMA)—law with a number of Medicare changes, including a prescription drug benefit • Medicare Part D—voluntaryMedicare prescription drug reimbursement plans

  10. 10-10 10.3 Medicare Coverage and Benefits • Common Working File (CWF)—Medicare’s master patient/procedural database • Medicare card—Medicare insurance identification card received by each member • Medicare health insurance claim number (HICN)—Medicare beneficiary’s identification number • Fiscal intermediary—government contractor that processes claims • Carriers—health plans that process claims sent by physicians, providers, and suppliers

  11. 10-11 10.3 Medicare Coverage and Benefits (Continued) • Medicare administrative contractor (MAC)—contractor who handles claims and related functions • Medicare Part B covers: • Physician services • Diagnostic X-rays and laboratory tests • Outpatient hospital visits • Durable medical equipment • Other nonhospital services

  12. 10-12 10.3 Medicare Coverage and Benefits (Continued) • Medicare Part B does not cover: • Most routine and custodial care • Examinations for eyeglasses or hearing aids • Some foot care procedures • Services not ordered by a physician • Cosmetic surgery • Health care received while traveling outside the United States • Procedures deemed not reasonable and medically necessary

  13. 10-13 10.3 Medicare Coverage and Benefits (Continued) • Initial preventive physical examination (IPPE)—the benefit of a preventive visit for new beneficiaries • Screening services—tests or procedures performed for a patient with no symptoms, abnormal findings, or relevant history • Excluded services and notmedically necessary services are not covered under any circumstances

  14. 10-14 10.4 Medicare Participating Providers • Participating providers agree to accept assignment for all Medicare claims and to accept Medicare’s fee as payment in full for services • Responsible for informing patients when services will not, or are not likely to be, paid by the program • Must comply with numerous billing rules such as global periods • Health Professional Shortage Area (HPSA)—geographical area offering participation bonuses to physicians

  15. 10-15 10.4 Medicare Participating Providers (Continued) • Advance beneficiary notice of noncoverage (ABN)—form used to inform patients that a service is not likely to be reimbursed • Local coverage determination (LCD)—notices sent to physicians with information about the coding and medical necessity of a service • National coverage determination (NCD)—policy stating whether and under what circumstances a service is covered • Notifier—provider who completes the header on an ABN

  16. 10-16 10.5 Nonparticipating Providers • Nonparticipating providers choose whether to accept assignments on a claim-by-claim basis • NonPAR providers are allowed 5 percent less than PAR providers on assigned claims • On unassigned claims, nonPAR providers are subject to Medicare’s limiting charges • Limiting charge—highest fee nonparticipating physicians may charge for a particular service

  17. 10-17 10.6 Original Medicare Plan • The Original Medicare Plan is a fee-for-service plan that provides maximum freedom of choice when selecting a provider or specialist • Patients are responsible for an annual deductible and a small portion of the bills • Patients receive a Medicare Summary Notice (MSN)—remittance advice from Medicare to beneficiaries detailing their services and charges

  18. 10-18 10.7 Medicare Advantage Plans • Medicare Advantage—group of managed care plans other than the Original Medicare Plan • Medicare Advantage offers three major types of plans: 1. Medicare coordinated care plans (CCPs) 2. Medicare private fee-for-service plans 3. Medical Savings Accounts (MSAs)— Medicare health savings account program • Urgently needed care—beneficiary’s unexpected illness or injury requiring immediate treatment

  19. 10-19 10.8 Medigap Insurance • Medigap—plan offered by a private insurance carrier to supplement coverage • Pays for services not covered by Medicare • Coverage varies, but all provide coverage for patient deductibles and coinsurance • Some also cover excluded services such as prescription drugs and limited preventive care

  20. 10-20 10.9 Medicare Billing and Compliance • Physician Quality Reporting Initiative (PQRI)—voluntary reporting program in which physicians or other professionals collect and report their practice data • Goal is to determine best practices, define measures, support involvement, and improve systems • Medical Review (MR) Program—payer’s procedures for ensuring patients are given appropriate care in a cost-effective manner • The Medicare Recovery Audit Contractor (RAC) program aims to ensure that claims paid by the MACs are correct

  21. 10-21 10.9 Medicare Billing and Compliance (Continued) • Quality Improvement Organization (QIO)—group of physicians paid by the government to review the Medicare program • Clinical Laboratory Improvement Amendments(CLIA)—law establishing standards for laboratory testing • Waived tests—low-risk laboratory tests that physicians perform in their offices

  22. 10-22 10.9 Medicare Billing and Compliance (Continued) • Incident to—services of allied health professionals provided under the physician’s direct supervision that may be billed under Medicare • Roster billing—simplified billing for vaccines

  23. 10-23 10.10 Preparing Primary Medicare Claims • Electronic claims are faster than paper claims • Medical insurance specialists must be aware of the required data elements when submitting Medicare claims

More Related