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

MedicareMedicare

Chapter 12Chapter 12

Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

22Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

Policies and RegulationsPolicies and Regulations

Centers for Medicare and Medicaid Services Centers for Medicare and Medicaid Services (CMS) Divisions(CMS) Divisions

Center for Medicare ManagementCenter for Medicare Management Center for Beneficiary ChoicesCenter for Beneficiary Choices Center for Medicaid and State OperationsCenter for Medicaid and State Operations


Eligibility RequirementsEligibility Requirements

People 65+ who are retired on Social SecurityPeople 65+ who are retired on Social Security People 65+ who are retired from railroad or People 65+ who are retired from railroad or

civil servicecivil service DisabledDisabled Children and adults with kidney diseaseChildren and adults with kidney disease Kidney donorsKidney donors


Health Insurance CardHealth Insurance Card


Medicare Part A:Medicare Part A:Hospital BenefitsHospital Benefits

hospital up to 90 dayshospital up to 90 days nursing facility up to 100 daysnursing facility up to 100 days home healthcare serviceshome healthcare services psychiatric hospitalpsychiatric hospital hospice carehospice care respite carerespite care


Medicare Part B: Medical Medicare Part B: Medical BenefitsBenefits

medical expensesmedical expenses clinical laboratory servicesclinical laboratory services home health carehome health care outpatient hospital careoutpatient hospital care bloodblood


Medicare Part C:Medicare Part C:MedicareMedicare Advantage Plan Advantage Plan

Available plans:Available plans: HMOHMO POSPOS PPOPPO PFFSPFFS PSOPSO RFBSRFBS MSA (pilot)MSA (pilot)


Medicare Part DMedicare Part D

Prescription drug benefitPrescription drug benefit Effective January 1, 2006Effective January 1, 2006 Eligible Medicare/Medicaid member pays no Eligible Medicare/Medicaid member pays no

premium or deductiblepremium or deductible Tiered drug planTiered drug plan Check Medicare information for authorization Check Medicare information for authorization

requirementsrequirements


Railroad Retirement BenefitsRailroad Retirement Benefits

Medical insurance premiums automatically Medical insurance premiums automatically deducteddeducted

Entitled to benefits for covered services at a Entitled to benefits for covered services at a qualified American facilityqualified American facility

Some may be member ofSome may be member of Railroad hospital association Railroad hospital association Prepayment plansPrepayment plans Contracts with MedicareContracts with Medicare


Employed Elderly BenefitsEmployed Elderly Benefits

Federal laws and regulations:Federal laws and regulations: Omnibus Budget Reconciliation Act (OBRA)Omnibus Budget Reconciliation Act (OBRA) Tax Equity and Fiscal Responsibility Act (TEFRA)Tax Equity and Fiscal Responsibility Act (TEFRA) Deficit Reduction Act (DEFRA)Deficit Reduction Act (DEFRA) Consolidated Omnibus Budget Reconciliation Act Consolidated Omnibus Budget Reconciliation Act

(COBRA)(COBRA) Tax Reform ActTax Reform Act


Determining if Medicare is Determining if Medicare is Primary or SecondaryPrimary or Secondary

Ask about other insurance.Ask about other insurance. Copy Medicare card.Copy Medicare card. Ask about supplemental coverage.Ask about supplemental coverage. Call the carrier.Call the carrier. Bill correctly.Bill correctly.


Medicare Managed Care PlansMedicare Managed Care Plans

Health Maintenance OrganizationsHealth Maintenance Organizations risk planrisk plan cost plancost plan noncontract physiciannoncontract physician

Carrier dealing prepayment organization Carrier dealing prepayment organization


Utilization and Quality ControlUtilization and Quality Control

Quality Improvement Organization (QIO)Quality Improvement Organization (QIO) Federal False Claims Amendment ActFederal False Claims Amendment Act Clinical Laboratory Improvement Amendment Clinical Laboratory Improvement Amendment

(CLIA)(CLIA)


HIPAA Compliance AlertHIPAA Compliance Alert

Some Medicare billing compliance issues Some Medicare billing compliance issues include:include: Reassignment of paymentReassignment of payment Correct procedure code assignment and service Correct procedure code assignment and service

utilizationutilization Accurate diagnostic code assignmentAccurate diagnostic code assignment Documentation related to selection of procedural Documentation related to selection of procedural

codes for services performedcodes for services performed Correct coding initiative editsCorrect coding initiative edits


Payment Payment FundamentalsFundamentals

par/nonparpar/nonpar limiting chargelimiting charge prior authorizationprior authorization waiver of liability provisionwaiver of liability provision elective surgery estimateelective surgery estimate prepayment screensprepayment screens Correct Coding IntiativeCorrect Coding Intiative


Medicare ReimbursementMedicare Reimbursement

chronology of Prospective Payment System chronology of Prospective Payment System (PPS)(PPS)

reasonable feereasonable fee resource-based relative value scaleresource-based relative value scale Healthcare Common Procedure Coding Healthcare Common Procedure Coding

System (HCPCS)System (HCPCS) Physician Quality Reporting Initiative (PQRI)Physician Quality Reporting Initiative (PQRI)


Medicare Reimbursement Medicare Reimbursement (cont’d.)(cont’d.)

RBRVS Formula:RBRVS Formula:

RVU x GAF x CF = Medicare $ per serviceRVU x GAF x CF = Medicare $ per service


Claim SubmissionClaim Submission

local coverage determinationlocal coverage determination MACs and FIsMACs and FIs provider identification numbersprovider identification numbers patient’s signature authorizationpatient’s signature authorization time limit – 1 year from date of servicetime limit – 1 year from date of service paper/electronic claimspaper/electronic claims


Provider Identification NumbersProvider Identification Numbers

PINsPINs UPINsUPINs PPINsPPINs NPINPI DMEDME EINEIN


Claim Submission (cont’d) Claim Submission (cont’d)

Medicare/Medicaid claimsMedicare/Medicaid claims Medicare/Medigap claimsMedicare/Medigap claims Medicare/Employer supplemental insurance Medicare/Employer supplemental insurance

claimsclaims Medicare/Supplemental and MSP claimsMedicare/Supplemental and MSP claims claims for deceased patientsclaims for deceased patients physician substitute coverage – modifiers physician substitute coverage – modifiers ––Q5 and –Q6Q5 and –Q6


After Claim SubmissionAfter Claim Submission

remittance advice (RA)remittance advice (RA) Medicare summary notice (MSN)Medicare summary notice (MSN) posting paymentsposting payments review and redetermination processreview and redetermination process


Medicare OverpaymentsMedicare Overpayments

charges processed more than oncecharges processed more than once duplicate payments from Medicare and duplicate payments from Medicare and

secondary payersecondary payer physician is paid directly, unassignedphysician is paid directly, unassigned errorerror

Documents

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