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Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
Issues and Trends in HBI Ch 10
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Issues and Trends in HBI Ch 10

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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: 10.1 Discuss the purpose of the Medicaid program.
    Teaching Notes:
    Ask students to identify how candidates can qualify and apply for Medicaid benefits (people applying for Medicaid benefits must meet minimum federal requirements and any additional requirements of the state in which they live).
    Examine and discuss with students how the FMAP improves coverage for categorically needy patients.
  • Learning Outcome: 10.2 Discuss general eligibility requirements for Medicaid.
    Teaching Notes:
     
    Ask students to provide three examples of how TANF can protect families and improve healthcare.
    Optional Assignment:
    Ask students to research Medicaid eligibility requirements at www.medicaid.gov/ and write a short paragraph describing what they have learned.
  • Learning Outcome: 10.2 Discuss general eligibility requirements for Medicaid.
    Teaching Notes:
     
    Examine and discuss with students the eligibility requirements for the categorically needy to qualify for Medicaid. Are the requirements too strict, too lenient, or appropriate?
  • Learning Outcome: 10.2 Discuss general eligibility requirements for Medicaid.
    Teaching Notes:
     Federal guidelines mandate that Medicaid cover certain services.
  • Learning Outcome: 10.2 Discuss general eligibility requirements for Medicaid.
    Teaching Notes:
     
    Identify and discuss with students how CHIP and EPSDT protect families and improve healthcare.
    Examine and discuss the advantages and/or disadvantages of the Welfare Reform Act as it relates to healthcare.
    Optional Assignment:
    Ask students to research the Welfare Reform Act and write a short paragraph describing their point of view on this act.
  • Learning Outcome: 10.3 Assess the income and asset guidelines used by most states to determine eligibility.
    Teaching Notes:
     
    Identify and discuss with students the advantages or disadvantages of states establishing their own eligibility standards.
    Examine and discuss with students how effective the application process is as it relates to eligibility.
    Optional Assignment:
    Ask students to write a paragraph that identifies two reasons why the patient is asked if assets have recently been transferred into another person’s name.
  • Learning Outcome: 10.3 Assess the income and asset guidelines used by most states to determine eligibility.
    Teaching Notes:
     
    Ask students to define medically needy and provide an example of how a patient applies for assistance.
    Examine and discuss with students the advantages and/or disadvantages of spenddown as it relates to the patient.
  • Learning Outcome: 10.4 Evaluate the importance of verifying a patient’s Medicaid enrollment.
    Teaching Notes:
     
    Examine and discuss with students the need to verify a patient’s eligibility at the time of each visit. Discuss verification strategies.
    Ask students to provide an example of how verification and accuracy can help ensure reimbursement.
  • Learning Outcome: 10.4 Evaluate the importance of verifying a patient’s Medicaid enrollment.
    Teaching Notes:
     
    Examine and discuss with students why some patients are placed on restricted status (in restricted status, a patient is required to use a specific provider).
    Ask students to provide examples of how MIP can reduce fraud and abuse.
    Optional Assignment:
    Ask students to research the Medicaid Integrity Program at www.medicaid.gov/ and write a short paragraph describing what they have learned.
  • Learning Outcome: 10.5 Explain the services that Medicaid usually does not cover.
    Teaching Notes:
     
    Identify and discuss with students the differences between state medical coverages (see the bulleted list on page 369).
    Ask students to provide three examples of cosmetic services that are denied and three that are covered.
  • Learning Outcome: 10.6 Describe the types of plans that states offer Medicaid recipients.
    Teaching Notes:
     
    Identify and discuss with students the advantages and/or disadvantages of fee-for-service plans (see the bulleted list on page 371).
    Ask students to describe the differences between managed care plans and fee-for-service plans.
  • Learning Outcome: 10.7 Discuss the claim filing procedures when a Medicaid recipient has other insurance coverage.
    Teaching Notes:
     
    Examine and discuss with students the reasons why it is important to verify other possible insurance carriers prior to submitting to Medicaid.
    Ask students to explain why Medicaid is the payer of last resort and to describe what will occur if other insurance carriers are available for billing.
  • Learning Outcome: 10.7 Discuss the claim filing procedures when a Medicaid recipient has other insurance coverage.
    Teaching Notes:
     
    Examine and discuss with students why some patients can be covered by both Medicare and Medicaid.
    Ask students to explain how crossover claims improve the reimbursement process.
  • Learning Outcome: 10.8 Prepare accurate Medicaid claims.
    Teaching Notes:
     
    Identify and discuss with students common unacceptable billing practices for physicians who contract with Medicaid (billing for services that are not medically necessary; billing for services not provided or billing more than once for the same procedure; submitting claims for individual procedures that are part of a global procedure; and submitting claims using an individual provider NPI when a physician working for or on behalf of a group practice or clinic performs services).
    Ask students to provide three strategies to improve the accuracy of the Medicaid reimbursement process.
    Optional Assignment:
    Ask students to write a short paragraph describing how visiting www.medicaid.gov/ can ensure that a medical insurance specialist stays up-to-date with compliance.
  • Transcript

    • 1. CHAPTER 10 Medicaid © 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. Learning Outcomes 10-2 When you finish this chapter, you will be able to: 10.1 10.2 10.3 Discuss the purpose of the Medicaid program. Discuss general eligibility requirements for Medicaid. Assess the income and asset guidelines used by most states to determine eligibility. 10.4 Evaluate the importance of verifying a patient’s Medicaid enrollment. 10.5 Explain the services that Medicaid usually does not cover.
    • 3. Learning Outcomes (continued) 10-3 When you finish this chapter, you will be able to: 10.6 Describe the types of plans that states offer Medicaid recipients. 10.7 Discuss the claim filing procedures when a Medicaid recipient has other insurance coverage. 10.8 Prepare accurate Medicaid claims.
    • 4. 10-4 Key Terms • categorically needy • Children’s Health Insurance Program (CHIP) • crossover claim • dual-eligible • Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) • Federal Medicaid Assistance Percentage (FMAP) • Medicaid Integrity Program (MIP) • MediCal • medically needy • Medi-Medi beneficiary • payer of last resort • restricted status • spenddown • Temporary Assistance for Needy Families (TANF) • Welfare Reform Act
    • 5. 10.1 The Medicaid Program 10-5 • Medicaid was established to pay for the healthcare needs of individuals and families with low incomes and few resources • Federal Medicaid Assistance Percentage (FMAP)—basis for federal government Medicaid allocations to states
    • 6. 10.2 Eligibility 10-6 • Federal guidelines mandate coverage for individuals referred to as categorically needy— people who receive assistance from government programs • Temporary Assistance for Needy Families (TANF)—program that provides cash assistance for low-income families
    • 7. 10.2 Eligibility (continued) 10-7 • Medicaid coverage is available to: – People receiving TANF assistance – People eligible for TANF but not receiving assistance – People receiving foster care or adoption assistance under the Social Security Act – Children under six years of age from low-income families – Some people who lose cash assistance when their work income or Social Security benefits exceed allowable limits – Infants born to Medicaid-eligible pregnant women
    • 8. 10.2 Eligibility (continued) 10-8 • Medicaid coverage is available to (continued): – People age sixty-five and over or legally blind or totally disabled people who receive Supplemental Security Income (SSI) – Certain low-income Medicare recipients • The federal government requires the states to provide individuals in certain low-income or lowresource categories with Medicaid coverage
    • 9. 10.2 Eligibility (continued) 10-9 • Children’s Health Insurance Program (CHIP) —offers health insurance coverage for uninsured children • Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)—Medicaid’s prevention, early detection, and treatment program for eligible children under twenty-one • Welfare Reform Act—law that established TANF and tightened Medicaid eligibility requirements
    • 10. 10.3 State Programs • States establish their own eligibility standards • When determining eligibility, states examine a person’s: – Income – Current assets (some assets are not counted) – Assets that have recently been transferred into another person’s name 10-10
    • 11. 10.3 State Programs (continued) 10-11 • Medically needy—classification for people with high medical expenses and low financial resources • MediCal—California’s Medicaid program • Spenddown—state-based Medicaid program requiring beneficiaries to pay part of their monthly medical expenses
    • 12. 10.4 Medicaid Enrollment Verification 10-12 • Patients’ eligibility should be checked each time they make an appointment and before they see a physician – Patient’s Medicaid identification cards should be checked; in addition, a second form of identification is often checked • Many states are developing the electronic verification of eligibility, in addition to telephone verification systems
    • 13. 10.4 Medicaid Enrollment Verification (continued) 10-13 • Restricted status—category of Medicaid beneficiary • Medicaid Integrity Program (MIP)—created to prevent and reduce fraud, waste, and abuse in Medicaid
    • 14. 10.5 Covered and Excluded Services 10-14 • States must cover certain services to receive federal matching funds – Some states also provide coverage for prescription drugs, dental or vision care, and other miscellaneous services • Medicaid usually does not pay for: – Services that are not medically necessary – Procedures that are experimental or investigational – Cosmetic procedures
    • 15. 10.6 Plans and Payments 10-15 • States offer a variety of plans, including fee-forservice and managed care plans – The trend is to shift recipients from fee-for-service plans to managed care plans • A physician who wishes to provide services to Medicaid recipients must sign a contract with the Department of Health and Human Services (HHS)
    • 16. 10.7 Third-Party Liability 10-16 • Before filing a claim with Medicaid, it is important to determine whether the patient has other insurance coverage – Other plan is billed first, then once the remittance advice from the primary carrier has been received, Medicaid may be billed • Payer of last resort—regulation that Medicaid pays last on a claim
    • 17. 10.7 Third-Party Liability (continued) 10-17 • Medi-Medi beneficiary—person eligible for both Medicare and Medicaid – Dual-eligible—Medicare-Medicaid beneficiary • Crossover claim—claim for a Medicare or Medicaid beneficiary
    • 18. 10.8 Claim Filing and Completion Guidelines 10-18 • Medical insurance specialists follow the general instructions for correct claims and also enter particular Medicaid data elements • They need to know: – – – – Where to file claims Proper Medicaid coding methods Unacceptable billing practices Actions to take after filing a claim
    • 19. Summary
    • 20. Summary
    • 21. Summary

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