CHAPTER 1       REIMBURSEMENT, HIPAA,          AND COMPLIANCECopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2...
Third-Party        Reimbursement Issues        • Each coding system plays critical role          in reimbursement        •...
Your Responsibility        • Ensure accurate coding data        • Obtain correct reimbursement for          services rende...
Population Changing        • Elderly fastest growing patient segment        • By 2050, 20% of the population will be the  ...
Medicare—Getting Bigger        All the Time!        • By 2018, national health care spending          expected to reach $4...
Basic Structure Medicare        • Medicare program established in 1965               – 2 parts: A and B        • Part A : ...
Those Covered        • Originally established for those 65          and over        • Later disabled and permanent renal  ...
Officiating Office        • _____________________________          Department of Health and Human          ________ (DHHS)...
Funding for Medicare        • Social security taxes               – Equal match from government        • CMS sends money t...
Medicare Covers (Part B)        • Beneficiary pays               – 20 % of cost of service                 __             ...
Non-participating QIO        Providers        • Payment sent to patient        • Non-QIOs receive 5% less than          pa...
Participating QIO Providers        • Signed agreement with MACs        • Agree to accept what MACs pay as          payment...
(…Cont’d)        • Block 27 on          CMS-1500,          Accept          Assignment                                     ...
Why Be a        Participating Provider?        • MACs usually do not pay charges          provider submits               –...
More Good Reasons        to Participate:        (…Cont’d)        • Check sent directly from MACs to          participating...
Part A, Hospital        • Hospitals submit charges on UB04                                      _____        • ICD-9-CM co...
Part A, Covered        In-Hospital Expenses        (…Cont’d)        • Semiprivate room        • Meals and special diets in...
Part A, Non-Covered        In-Hospital Expenses        (…Cont’d)        • Personal convenience items        • Example:    ...
Part A, Other Covered        Expenses        (…Cont’d)        • Rehabilitation                                            ...
Part B, Supplemental        • Part B pays services and supplies not          covered under Part A        • Not automatic  ...
Type of Items Covered by Part B        (…Cont’d)        • Physicians’ services        • Outpatient hospital services      ...
Coding for Medicare        Part B Services        • Three coding systems used to          report Part B               – CP...
Health Insurance Portability        and Accountability Act        • Established 1996        • Administrative Simplificatio...
Federal Register        • Government publishes changes in laws        • Coding supervisors keep current on          change...
Issues of Importance in        Federal Register        (…Cont’d)        • October contains hospital facility          ____...
Federal        Register                   Figure: 1.3                   From Federal Register,                   August 3,...
Outpatient Resource–Based        Relative Value Scale        • RBRVS        • Physician payment reform          implemente...
National Fee Schedule        • Replaced RBRVS        • Termed Medicare Fee Schedule (MFS)        • Payment 80 % of MFS, af...
Relative Value Unit        • Nationally, unit values assigned          to each CPT code        • Local adjustments made:  ...
Relative Value Unit        (…Cont’d)        • Often referred to as ___ schedule                               fee        •...
Geographic Practice Cost Index        (GPCI) and Conversion Factor (CF)        • GPCI: Geographic Practice Cost Index     ...
Medicare Fraud and Abuse        • Program established by Medicare               – To decrease fraud and abuse        • Fra...
Beneficiary Signatures        • Beneficiary signatures on file               – Service, charges submitted without need    ...
Fraud        (…Cont’d)        • Anyone who submits for Medicare          services can be violator               – Physicia...
Fraud Can Be        • Billing for services not provided        • Misrepresenting diagnosis        • Kickbacks        • Unb...
Office of the Inspector        General (OIG)        • Each year develops work plan        • Outlines monitoring Medicare p...
Complaints of Fraud or Abuse        • Submitted orally or in writing to MACs or OIG        • Allegations made by anyone ag...
Abuse        • Generally involves               – Impropriety               – Lack of medical necessity for services      ...
Kickbacks        • Bribe or rebate for referring patient for          any service covered by Medicare        • Any persona...
Protect Yourself        • Use your common sense        • Submit only truthful and accurate          claims        • If you...
Managed Health Care        • Network health care providers that          offer health care services under one          org...
Managed Care        Organizations        (…Cont’d)        • Responsible for health care services          to an enrolled g...
Preferred Provider        Organization (PPO)        • Providers form network to offer health          care services as gro...
Health Maintenance        Organization (HMO)        • Total package health care        • Out-of-pocket expenses minimal   ...
Drawbacks of Managed Care        • Organization has incentive to keep          patient within organization               –...
Conclusion                        CHAPTER 1       REIMBURSEMENT, HIPAA,          AND COMPLIANCECopyright © 2011, 2010, 200...
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  • SXS11ierPPTINTC01_P1
  • SXS11ierPPTINTC01_P1 Who is the largest third-party payer in the U.S.? (Medicare)
  • SXS11ierPPTINTC01_P1 • What is the coder’s role? (To accurately code the services and procedures rendered so that the office is properly reimbursed) • Ethical issues will continually surface and must be handled by coders. What are some examples? (Pressure to upcode a procedure, to restate a diagnosis to obtain better payment) • Upcoding, assigning comorbidity/complications based only on laboratory values, and using nonphysician impressions or assessments without physician agreement are fraudulent.
  • SXS11ierPPTINTC01_P1 What issues do population changes create for the health care industry? (As people live longer, and as the baby boomers start to reach retirement, the elderly population will increase, creating greater use of health care services and Medicare becomes an even greater component of a medical office ’s revenues.)
  • SXS11ierPPTINTC01_P1 • Increasing numbers of elderly people, technological advances, and improved access to health care have increased consumer use of health care services.
  • SXS11ierPPTINTC01_P1 The Medicare program was established in 1965 with the passage of the Social Security Act. The program dramatically increased the government ’s involvement in health care. What are the advantages and disadvantages of this? (Advantage: more elderly and disabled people have access to affordable health care. Disadvantage: government involvement brings bureaucracy and complicated regulations.)
  • SXS11ierPPTINTC01_P1 Individuals covered under Medicare are called “beneficiaries.”
  • SXS11ierPPTINTC01_P1 • CMS was formerly HCFA, the Health Care Financing Administration. • What are the responsibilities of the CMS? (CMS operates Medicare, using Medicare Administrative Contractors or Fiscal Intermediaries, private insurance companies that handle Medicare in specific areas.) • There are currently 48 FIs to 19 MACs.
  • SXS11ierPPTINTC01_P1 The funds to run Medicare are generated from payroll taxes paid by employers and employees. Who collects and handles Medicare funds? (Social Security Administration collects and handles the funds, which flow through CMS to the MACs or FIs.)
  • SXS11ierPPTINTC01_P1 Medicare pays 80% of covered charges, and the beneficiary pays the remaining 20% (the coinsurance payment). What else does the beneficiary pay? (Deductibles, premiums, and noncovered services). Beneficiaries often choose to purchase additional insurance to cover out-of-pocket expenses.
  • SXS11ierPPTINTC01_P1 • What are providers? (Physicians, hospitals, and other suppliers that provide care or supplies to Medicare beneficiaries) • Providers must be licensed by local and state health agencies to be eligible to provide services or supplies to Medicare patients. • Providers can sign a participating provider agreement (PAR) with a fiscal intermediary to accept assignment on all claims submitted to Medicare. • Approximately what percentage of physicians in the U.S. are participating providers? (50%) • Accepting assignment means that the provider will accept what Medicare allows and not bill the patient for the difference between what the service costs and what Medicare pays.
  • SXS11ierPPTINTC01_P1 Describe the image on the figure.
  • SXS11ierPPTINTC01_P1 Why might a provider agree to become a participating provider? (PARs are paid according to a fee schedule that is 5% higher than that for nonparticipating providers.)
  • SXS11ierPPTINTC01_P1 What are the basic guidelines for nonparticipating providers (nonpars)? (Payment goes to the patient; fee schedule is 5% lower; claims are processed more slowly; statement on the explanation of benefits sent to the patient reminds the patient that using a participating provider will lower out-of-pocket expenses.) Fiscal intermediaries are paid a bonus for each provider they recruit who enrolls as a participating provider.
  • SXS11ierPPTINTC01_P1 Hospitals report services for Part A by using ICD-9-CM codes and the DRG assignment. UB04, also called CMS-1450 (formerly UB92), is the insurance form used by inpatient facilities for claims submissions. What determines eligibility for Part A? (Beneficiaries are automatically eligible for Part A when they become eligible for Medicare.)
  • SXS11ierPPTINTC01_P1 This is a listing of services that are covered by Medicare Part A. Medicare Part A would cover the basics of a hospital stay. A way to look at it would be a “No Frills” stay.
  • SXS11ierPPTINTC01_P1 This is a listing of services that are not covered by Medicare Part A. Anything that Medicare would deem not medically necessary would not be covered under Medicare Part A for a hospital stay.
  • SXS11ierPPTINTC01_P1 Part A can also help pay for inpatient care in a Medicare-certified skilled nursing facility if the patient ’s condition requires daily skilled nursing or rehabilitation services that can be provided only in this type of facility.
  • SXS11ierPPTINTC01_P1 Part B is not automatically provided to beneficiaries when they become eligible for Medicare. Medicare Part B, like Blue Cross of North Dakota for example, is an insurance the individual purchases and pays monthly premiums. Currently, Medicare Part B reimburses at a rate of 80%. Which means that if the patient does not have a secondary insurance the patient will be responsible for the other 20%.
  • SXS11ierPPTINTC01_P1 Part B helps to pay for medically necessary physician ’s services, outpatient hospital services, home health care, and a number of other medical services and supplies that are not covered by Part A.
  • SXS11ierPPTINTC01_P1 What is each type of code used for? (Diagnoses, procedure, additional supplies and services, respectively) What is Part C? (Medicare + Choice program: provides a set of options from which beneficiaries can choose their health care providers; some options are HMO, POS, PPO, and MSA [medical savings account]) What is Part D? (New prescription drug benefit for beneficiaries. Beginning in January 2006, beneficiaries could enroll in Part D and choose from plans that offered drug coverage.)
  • SXS11ierPPTINTC01_P1 What is the Federal Register? (The official publication for all Presidential Documents, Rules and Regulations, Proposed Rules, and Notices.) Coders must be aware of changes listed in the Federal Register that relate to Medicare reimbursement so that Medicare charges will be submitted correctly. Because the government is the largest third-party payer in the nation, even small changes in rules governing reimbursement to providers can have major consequences.
  • SXS11ierPPTINTC01_P1 Each year proposed changes to the various payment systems are published early. Several months pass so that interested parties can comment and make suggestions about the proposed changes. The final rules are published in the fall editions. Changes are implemented the following calendar year.
  • SXS11ierPPTINTC01_P1 • A sample page of the Federal Register (Fig 1-3) is available in the text.
  • SXS11ierPPTINTC01_P1 Why was physician payment reform implemented? (To decrease Medicare expenditures, to redistribute physicians ’ payments more equitably, to ensure quality health care at a reasonable rate) OBRA 1990 required that before January 1 of each year, beginning in 1992, fee schedules that determine payment amounts for all physician services would be established.
  • SXS11ierPPTINTC01_P1 All physicians are paid on the amounts of the Medicare fee schedule.
  • SXS11ierPPTINTC01_P1 How are unit values determined? (The amount of time, effort, and technical expertise required, overhead, cost of malpractice coverage) A Harvard University group analyzed a service, identified its separate parts, and assigned each part a relative value unit. These parts, or components of service, are work (time, effort, and skill), overhead, and malpractice. The sum of the units established for each component of the service equals the total RVUs of a service.
  • SXS11ierPPTINTC01_P1 What is the Geographic Practice Cost Index and the Conversion Factor? (National dollar amount that is applied to all services paid according to the Medicare Fee Schedule.)
  • SXS11ierPPTINTC01_P1 Medicare defines fraud as “the intentional deception or misrepresentation that an individual knows to be false and does not believe to be true and makes it knowing that the deception could result in some unauthorized benefit to himself/herself or to some other person.” What are some examples of fraud? (Altering medical records, upcoding, phantom billing, double-billing for same service, etc.)
  • SXS11ierPPTINTC01_P1 Most Medicare patients sign a standing approval, which is kept on file in the medical office. This allows Medicare claims to be filed automatically, which makes it easy for an unscrupulous person to submit charges for services that were never provided.
  • SXS11ierPPTINTC01_P1 Coders must validate that the service was actually provided by consulting the medical record or the physician.
  • SXS11ierPPTINTC01_P1 Discuss how medical professionals, especially coders, should react if they suspect fraud.
  • SXS11ierPPTINTC01_P1 Office of the Inspector General (OIG) is responsible for developing a work plan that outlines the ways in which the Medicare program is monitored to identify fraud and abuse.
  • SXS11ierPPTINTC01_P1 Describe several circumstances in which coders may have to react to suspicious activities (by physician, patient, fellow coder, etc.).
  • SXS11ierPPTINTC01_P1 Abuse reviews involve checking the propriety or medical necessity of services that are billed; these reviews generally occur after claims processing activity. Fraud reviews may determine, for example, whether or not billed services were furnished.
  • SXS11ierPPTINTC01_P1 What is a “safe harbor” clause? (Protects against certain types of medical services being discounted) What are examples of what is or is not protected under the “safe harbor” clause? (Protected: An HMO contracts with a laboratory for all laboratory services and receives a discounted price; not protected: furnishing an item or service free of charge or at a reduced charge in exchange for any agreement to buy a different item or service.)
  • SXS11ierPPTINTC01_P1 Coders are one group that CMS holds responsible for submitting truthful and accurate claims.
  • SXS11ierPPTINTC01_P1 What is the purpose of managed health care? (To provide cost-effective services and improve the health care services provided to enrollees by ensuring access to care)
  • SXS11ierPPTINTC01_P1 The organization coordinates the total health care services required by its enrollees.
  • SXS11ierPPTINTC01_P1 PPO providers agree to provide services to enrollees at a discounted rate. Enrollees pay a portion of the costs when using a PPO provider. Out-of-pocket costs are greater when health care is obtained outside of the network. Patients have In Plan benefits and Out of Plan benefits.
  • SXS11ierPPTINTC01_P1 A Health Maintenance Organization (HMO) is a health care delivery system that allows the enrollee access to all health care services. Each enrollee is assigned a primary care gatekeeper who has the authority to allow the enrollee to access the services available or to authorize services outside of the HMO. HMO can employ the physician in a staff model HMO or can contract with the physician through the individual practice association (IPA) model in which the physician provides services for a set fee.
  • SXS11ierPPTINTC01_P1 Managed care requires patients to stay within the organization, and if the patient chooses to go outside of the network a prior approval or authorization is needed.
  • SXS11ierPPTINTC01_P1
  • Chapter 001

    1. 1. CHAPTER 1 REIMBURSEMENT, HIPAA, AND COMPLIANCECopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1
    2. 2. Third-Party Reimbursement Issues • Each coding system plays critical role in reimbursement • Your job is to optimize payment _______Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2
    3. 3. Your Responsibility • Ensure accurate coding data • Obtain correct reimbursement for services rendered • Upcoding (maximizing) is never ________ appropriateCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3
    4. 4. Population Changing • Elderly fastest growing patient segment • By 2050, 20% of the population will be the elderly • Medicare primarily for elderlyCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4
    5. 5. Medicare—Getting Bigger All the Time! • By 2018, national health care spending expected to reach $4.4 trillion • Health care will continue to expand to meet enormous future demands – Job security for coders!Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5
    6. 6. Basic Structure Medicare • Medicare program established in 1965 – 2 parts: A and B • Part A : Hospital insurance _ • Part B: Supplemental—nonhospital _ – Example: Physicians’ services and medical equipment • Part C: Medicare Advantage, health care options _ (Added later and formerly termed Medicare + Choice) • Part D: Prescription drugs _Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6
    7. 7. Those Covered • Originally established for those 65 and over • Later disabled and permanent renal disease (end-stage or transplant) added beneficiaries • Persons covered “___________”Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7
    8. 8. Officiating Office • _____________________________ Department of Health and Human ________ (DHHS) Services • Delegated to Centers for Medicare and Medicaid Services (CMS) – CMS runs Medicare and Medicaid – CMS delegates daily operation to Medicare Administrative Contractors (MAC) – MACs usually insurance companiesCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8
    9. 9. Funding for Medicare • Social security taxes – Equal match from government • CMS sends money to MACs • MACs handles paperwork and pays claimsCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9
    10. 10. Medicare Covers (Part B) • Beneficiary pays – 20 % of cost of service __ – + annual _________ deductible • Medicare pays – 80% covered services __Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10
    11. 11. Non-participating QIO Providers • Payment sent to patient • Non-QIOs receive 5% less than participating QIOs • Slower claims processingCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11
    12. 12. Participating QIO Providers • Signed agreement with MACs • Agree to accept what MACs pay as payment in full – Accept Assignment • Block __ on CMS-1500 27 (Cont’d…)Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12
    13. 13. (…Cont’d) • Block 27 on CMS-1500, Accept Assignment Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13
    14. 14. Why Be a Participating Provider? • MACs usually do not pay charges provider submits – Significant decrease • Participating providers receive 5 % _ more than non-participating (Cont’d…)Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14
    15. 15. More Good Reasons to Participate: (…Cont’d) • Check sent directly from MACs to participating provider • ______ claims processing Faster • Provider names listed in a directory ________ beneficiaries – Sent to all _____________Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15
    16. 16. Part A, Hospital • Hospitals submit charges on UB04 _____ • ICD-9-CM codes basis for payment – MS-DRG (Medicare Severity Diagnosis Related Groups) • More on this topic in Chapter 26 (Cont’d…)Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16
    17. 17. Part A, Covered In-Hospital Expenses (…Cont’d) • Semiprivate room • Meals and special diets in hospital • All medically necessary services (Cont’d…)Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17
    18. 18. Part A, Non-Covered In-Hospital Expenses (…Cont’d) • Personal convenience items • Example: – Slippers, TV – Non-medically necessary items (Cont’d…)Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18
    19. 19. Part A, Other Covered Expenses (…Cont’d) • Rehabilitation • Home health visits • Skilled-nursing • Hospice care • Some personal • Not automatically convenience items covered for long-term illness – Must meet certain or disabilities criteriaCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 19
    20. 20. Part B, Supplemental • Part B pays services and supplies not covered under Part A • Not automatic • Beneficiaries purchase premiums – Pay monthly __________ (Cont’d…)Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20
    21. 21. Type of Items Covered by Part B (…Cont’d) • Physicians’ services • Outpatient hospital services • Home health care • Medically necessary supplies _________________ and equipmentCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21
    22. 22. Coding for Medicare Part B Services • Three coding systems used to report Part B – CPT – HCPCS – ICD-9-CM (Vol. 1 & 2)Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22
    23. 23. Health Insurance Portability and Accountability Act • Established 1996 • Administrative Simplification • Largest change • Includes: – Electronic Transactions – Privacy – Security – National Identifier Requirements (NPI)Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23
    24. 24. Federal Register • Government publishes changes in laws • Coding supervisors keep current on changes (Cont’d…)Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24
    25. 25. Issues of Importance in Federal Register (…Cont’d) • October contains hospital facility _______ changes • _________ and December contain November _________ outpatient facility changes and physician fee scheduleCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 25
    26. 26. Federal Register Figure: 1.3 From Federal Register, August 3, 2010, Vol. 148, No. 8, Proposed Rules.Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 26
    27. 27. Outpatient Resource–Based Relative Value Scale • RBRVS • Physician payment reform implemented in 1992 • Paid physicians lowest of ______ – 1. Physician’s charge for service – 2. Physician’s _________ charge customary Prevailing – 3. _________ charge in localityCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 27
    28. 28. National Fee Schedule • Replaced RBRVS • Termed Medicare Fee Schedule (MFS) • Payment 80 % of MFS, after patient __ deductible • Used for physicians and suppliers ________Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 28
    29. 29. Relative Value Unit • Nationally, unit values assigned to each CPT code • Local adjustments made: 1. Work and skill required 2. Overhead costs ________ 3. Malpractice costs (Cont’d…)Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 29
    30. 30. Relative Value Unit (…Cont’d) • Often referred to as ___ schedule fee • ________, CMS updates RVU based on Annually national and local factors • Beneficiary Protection – Physician Payment Reform – Omnibus Budget Reconciliation Act of 1989 – Maximum Actual Allowable Charge (MAAC) 1991Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 30
    31. 31. Geographic Practice Cost Index (GPCI) and Conversion Factor (CF) • GPCI: Geographic Practice Cost Index – Scale of cost variance of charge locations • Charge location may be entire state • CF: Conversion Factor – National dollar amount – Paid on Medicare Fee Schedule basis – Converts RVUs to dollars – Updated yearlyCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 31
    32. 32. Medicare Fraud and Abuse • Program established by Medicare – To decrease fraud and abuse • Fraud – Intentional deception to benefit _________ • Example: – Submitting for services not providedCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 32
    33. 33. Beneficiary Signatures • Beneficiary signatures on file – Service, charges submitted without need for patient signature • Presents opportunity for _____ fraud (Cont’d…)Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 33
    34. 34. Fraud (…Cont’d) • Anyone who submits for Medicare services can be violator – Physicians – Hospitals – Laboratories – Billing services – YOU ____Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 34
    35. 35. Fraud Can Be • Billing for services not provided • Misrepresenting diagnosis • Kickbacks • Unbundling services __________ medical • Falsifying _______ necessity waiver • Routine ______ of copaymentCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 35
    36. 36. Office of the Inspector General (OIG) • Each year develops work plan • Outlines monitoring Medicare program • MACs monitor those areas identified _____ in planCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 36
    37. 37. Complaints of Fraud or Abuse • Submitted orally or in writing to MACs or OIG • Allegations made by anyone against anyone • Allegations followed up by MACsCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 37
    38. 38. Abuse • Generally involves – Impropriety – Lack of medical necessity for services reported • Review takes place after claim submitted – May go back and do historic review of claimsCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 38
    39. 39. Kickbacks • Bribe or rebate for referring patient for any service covered by Medicare • Any personal ____ = kickback gain • A felony – Fine or – Jail or – BothCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 39
    40. 40. Protect Yourself • Use your common sense • Submit only truthful and accurate claims • If you are unsure about charges physician – Check with _________ or supervisorCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 40
    41. 41. Managed Health Care • Network health care providers that offer health care services under one organization • Group hospitals, physicians, or other providers (Cont’d…)Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 41
    42. 42. Managed Care Organizations (…Cont’d) • Responsible for health care services to an enrolled group or person • Coordinates various health care services • Negotiates with providersCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 42
    43. 43. Preferred Provider Organization (PPO) • Providers form network to offer health care services as group • Enrollees who seek health care outside PPO pay more ________Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 43
    44. 44. Health Maintenance Organization (HMO) • Total package health care • Out-of-pocket expenses minimal ____________ • Assigned physician acts as gatekeeper __________ to refer patient outside organizationCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 44
    45. 45. Drawbacks of Managed Care • Organization has incentive to keep patient within organization – Services provided outside organization limited – Patient must have approval to go outside organization if services to be coveredCopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 45
    46. 46. Conclusion CHAPTER 1 REIMBURSEMENT, HIPAA, AND COMPLIANCECopyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 46

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