Issues and Trends in HBI Ch 9

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  • Teaching Notes:
     Suggest to students that they review the key terms in this chapter prior to reading the chapter or hearing the lecture. This will enhance their understanding of the material.
  • Learning Outcome: 9.1 List the eligibility requirements for Medicare program coverage.
    Teaching Notes:
    Ask students to research Medicare eligibility requirements at www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html and to summarize the main points in their own words.
  • Learning Outcome: 9.2 Differentiate among Medicare Part A, Part B, Part C, and Part D.
    Teaching Notes:
    Medicare is the most complex program that medical practices deal with.
    Numerous rules and regulations are involved in filing Medicare claims.
    Medicare recipients are called Medicare beneficiaries.
  • Learning Outcome: 9.2 Differentiate among Medicare Part A, Part B, Part C, and Part D.
    Teaching Notes:
     Medicare Advantage plans must offer all of the benefits covered under Parts A and B but do not have to offer them at the same rate.
    Part D is not needed if a beneficiary is covered under a Medicare Advantage program that includes drug coverage.
  • Learning Outcome: 9.3 Contrast the types of medical and preventive services that are covered or excluded under Medicare Part B.
    Teaching Notes:
     
    Examine and discuss features of the Medicare card in Figure 9.1 with students.
    The Medicare number, called the Medicare Health Insurance Claim Number (HICN), is assigned by CMS and usually consists of the Social Security number followed by a numeric or alphanumeric ending.
    The letter at the end provides additional information about the patient, such as:.
    A stands for wage earner.
    B is for spouse’s number.
    D is for widow or widower
  • Learning Outcome: 9.3 Contrast the types of medical and preventive services that are covered or excluded under Medicare Part B.
    Teaching Notes:
     
    Ask students to describe how Medicare Part B differs from Part A.
  • Learning Outcome: 9.3 Contrast the types of medical and preventive services that are covered or excluded under Medicare Part B.
    Teaching Notes:
    Examine and discuss with students why they think the listed procedures in this slide are not covered by Medicare Part B.
    Ask students to provide three examples of when cosmetic surgeries can be covered by Medicare Part B (e.g., reconstructive surgery).
  • Learning Outcome: 9.3 Contrast the types of medical and preventive services that are covered or excluded under Medicare Part B.
    Teaching Notes:
     
    Examine and discuss with students how IPPEs, screening services, and AVPs improve healthcare.
    Ask students to provide an example of how the United States Preventive Services Task Force can help third-party payers reduce costs.
  • Learning Outcome: 9.4 Apply the process that is followed to assist a patient in completing an ABN form correctly.
    Teaching Notes:
     
    Annually, physicians choose whether they want to participate in the Medicare program. PARs agree to accept assignment for all Medicare claims, and to accept the Medicare Physician Fee Schedule as payment in full.
    PAR providers must know the rules of the Medicare program. The Internet-Only Manuals are the prime resource for day-to-day implementation guidelines.
  • Learning Outcome: 9.4 Apply the process that is followed to assist a patient in completing an ABN form correctly.
    Teaching Notes:
    Ask students to explain how the MLN and PQRS can help healthcare providers improve patient services.
    Explain the purpose of incentive programs such as PQRS, HPSA, and others.
  • Learning Outcome: 9.4 Apply the process that is followed to assist a patient in completing an ABN form correctly.
    Teaching Notes:
     
    Examine and discuss with students the five sections and ten blanks of the advance beneficiary notice (ABN) of noncoverage ((1) Header [Blanks A-C]; (2) Body [Blanks D-F]; (3) Options Box [Blank G]; (4) Additional Information [Blank H]; and (5) Signature Box [Blanks I-J]).
    (See Figure 9.3.)
    Ask students to provide an example of how LCD and NCD can help control cost constraints.
  • Learning Outcome: 9.5 Calculate fees for nonparticipating physicians when they do and do not accept assignment.
    Teaching Notes:
     For example: If a Medicare allowed charge is $100.00:
    The PAR provider would receive $80.00 (80% of 100.00).
    The nonPAR provider who accepts assignment would receive $76.00 ($80-5%).
    The nonPAR provider who does not accept assignment cannot receive more than the limiting charge assigned by Medicare.
  • Learning Outcome: 9.6 Outline the features of the Original Medicare Plan.
    Teaching Notes:
     Under the Original Medicare Plan, beneficiaries can choose any licensed physician who is certified by Medicare.
    What amount of a patient’s medical bills has been applied to the annual deductible is shown on the Medicare Remittance Notice (MRN), which is the RA that the office receives, and on the Medicare Summary Notice (MSN) that the patient receives.
  • Learning Outcome: 9.7 Discuss the features and coverage offered under Medicare Advantage plans.
    Teaching Notes:
     
    Examine and discuss the characteristics of the three major types of Medicare Advantage plans with students (use pages 340-341 as a reference).
    Ask students to provide examples of urgent care versus ordinary services that are usually obtained.
  • Learning Outcome: 9.8 Explain the coverage that Medigap plans offer.
    Teaching Notes:
     
    Examine and discuss with students the characteristics and advantages of services that are commonly covered by Medigap (the gaps covered by Medigap include the annual deductible, any coinsurance, and payment for some noncovered services).
  • Learning Outcome: 9.9 Discuss the Medicare, Medical Review (MR), recovery auditor, and ZPIC programs.
    Teaching Notes:
     CMS defines fraud as “making false statements or representations of material or facts in order to obtain some benefit or payment for which no entitlement would otherwise exist.” (www.CMS.gov)
    CMS defines abuse as “practices that, either directly or indirectly, result in unnecessary costs to the Medicare program.” (www.CMS.gov)
    Examine and discuss with students how the Medicare Integrity Program and MR programs improve the quality of healthcare.
    Ask students how Zone Program Integrity Contractors can help monitor fraud.
  • Learning Outcome: 9.9 Discuss the Medicare, Medical Review (MR), recovery auditor, and ZPIC programs.
    Teaching Notes:
     
    Examine and discuss with students how CLIA can improve the quality of laboratory testing standards.
     
  • Learning Outcome: 9.9 Discuss the Medicare, Medical Review (MR), recovery auditor, and ZPIC programs.
    Teaching Notes:
     
    Medical insurance specialists are trained to handle the special processing rules that govern both incident-to and roster billing.
  • Learning Outcome: 9.10 Prepare accurate Medicare primary claims.
    Teaching Notes:
     
    Refer to Figure 9.9 with students and examine and discuss the advantages of electronic claims.
    Ask students to provide and discuss strategies for ensuring correct and accurate information when submitting claims.
  • Issues and Trends in HBI Ch 9

    1. 1. CHAPTER 9 Medicare © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
    2. 2. Learning Outcomes 9-2 When you finish this chapter, you will be able to: 9.1 List the eligibility requirements for Medicare program coverage. 9.2 Differentiate among Medicare Part A, Part B, Part C, and Part D. 9.3 Contrast the types of medical and preventive services that are covered or excluded under Medicare Part B. 9.4 Apply the process that is followed to assist a patient in completing an ABN form correctly. 9.5 Calculate fees for nonparticipating physicians when they do and do not accept assignment.
    3. 3. Learning Outcomes (continued) When you finish this chapter, you will be able to: 9.6 9.7 Outline the features of the Original Medicare Plan. Discuss the features and coverage offered under Medicare Advantage plans. 9.8 Explain the coverage that Medigap plans offer. 9.9 Discuss the Medicare, Medical Review (MR), recovery auditor, and ZPIC programs. 9.10 Prepare accurate Medicare primary claims. 9-3
    4. 4. Key Terms • advance beneficiary notice of noncoverage (ABN) • annual wellness visit (AWV) • carrier • Clinical Laboratory Improvement Amendments (CLIA) • Common Working File (CWF) • cost sharing 9-4 • fiscal intermediary • Health Professional Shortage Area (HPSA) • incident-to services • initial preventive physical examination (IPPE) • Internet Only Manuals • limiting charge • local coverage determination (LCD)
    5. 5. Key Terms (continued) • Medical Review (MR) Program • Medical Savings Account (MSA) • Medicare administrative contractor (MAC) • Medicare Advantage • Medicare card • Medicare health insurance claim number (HICN) 9-5 • Medicare Integrity Program (MIP) • Medicare Learning Network (MLN) Matters • Medicare Modernization Act (MMA) • Medicare Part A (Hospital Insurance [HI]) • Medicare Part B (Supplementary Medical Insurance [SMI]) • Medicare Part C • Medicare Part D
    6. 6. 9-6 Key Terms (continued) • Medicare Summary Notice (MSN) • Medigap • national coverage determination (NCD) • notifier • Original Medicare Plan • Physician Quality Reporting System (PQRS) • • • • recovery auditor program roster billing screening service United States Preventive Services Task Force (USPSTF) • urgently needed care • waived tests • Zone Program Integrity Contractor (ZPIC)
    7. 7. 9.1 Eligibility for Medicare 9-7 • 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. 8. 9.2 The Medicare Program 9-8 • Medicare Part A (Hospital Insurance [HI])— program that pays for hospitalization, care in a skilled nursing facility, home healthcare, 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. 9. 9.2 The Medicare Program (continued) 9-9 • 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—voluntary Medicare prescription drug reimbursement plans
    10. 10. 9.3 Medicare Coverage and Benefits 9-10 • 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—prior name for government contractor that processes claims • Carrier—prior name for health plan that processes claims from providers
    11. 11. 9.3 Medicare Coverage and Benefits (continued) 9-11 • Medicare administrative contractor (MAC)— contractor who handles claims and related functions • Cost sharing – participating in deductible and coinsurance payment • Medicare Part B covers: – – – – – Physician services Diagnostic X-rays and laboratory tests Outpatient hospital visits Durable medical equipment Other nonhospital services
    12. 12. 9.3 Medicare Coverage and Benefits (continued) 9-12 • 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 Healthcare received while traveling outside the United States – Procedures deemed not reasonable and medically necessary
    13. 13. 9.3 Medicare Coverage and Benefits (continued) 9-13 • Initial preventive physical examination (IPPE) —preventive visit for new beneficiaries • Screening services—tests or procedures performed for a patient with no symptoms, abnormal findings, or relevant history • United States Preventive Services Task Force – develops recommendations for primary care clinicians and health systems • Annual wellness visit (AVP) – preventive service providing health risk assessment and personal prevention plan
    14. 14. 9.4 Medicare Participating Providers 9-14 • 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 • Internet-Only Manuals – operating instructions, policies, and procedures based on statutes and regulations, guidelines, models, and directives
    15. 15. 9.4 Medicare Participating Providers 9-15 • Medicare Learning Network (MLN) – online collection of articles that explain all Medicare topics • Health Professional Shortage Area (HPSA)— geographical area offering participation bonuses to physicians • Physician Quality Reporting System (PQRS) – quality reporting program in which physicians or other eligible professionals collect and report their practice data
    16. 16. 9.4 Medicare Participating Providers (continued) 9-16 • 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
    17. 17. 9.5 Nonparticipating Providers 9-17 • Nonparticipating providers choose whether to accept assignments on a claim-by-claim basis – NonPAR providers are allowed five 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
    18. 18. 9.6 Original Medicare Plan 9-18 • 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, a premium, 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
    19. 19. 9.7 Medicare Advantage Plans 9-19 • 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
    20. 20. 9.8 Additional Coverage Options 9-20 • 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
    21. 21. 9.9 Medicare Billing and Compliance 9-21 • Medicare Integrity Program – identifies and addresses fraud, waste, and abuse • Medical Review (MR) Program—payer’s procedures for ensuring patients are given appropriate care in a cost-effective manner • Medicare recovery auditor program is a postpayment claim review program • Zone Program Integrity Contractor (ZPIC) – antifraud agency that conducts both prepayment and postpayment audits
    22. 22. 9.9 Medicare Billing and Compliance (continued) • Clinical Laboratory Improvement Amendments (CLIA)—law establishing standards for laboratory testing • Waived tests—low-risk laboratory tests that physicians perform in their offices 9-22
    23. 23. 9.9 Medicare Billing and Compliance (continued) 9-23 • Incident-to services – services of allied health professionals provided under the physician’s direct supervision that may be billed under Medicare • Roster billing—simplified billing for vaccines
    24. 24. 9.10 Preparing Primary Medicare Claims 9-24 • Electronic claims are faster than paper claims • Medical insurance specialists must be aware of the required data elements when submitting Medicare claims
    25. 25. Summary
    26. 26. Summary
    27. 27. Summary
    28. 28. Summary

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