Chapter 12 HIT 212

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Chapter 12 HIT 212

  1. 1. Chapter 12: Medicare<br />
  2. 2. Regulated by Centers for Medicare and Medicaid Services (CMS)<br />Eligibility<br />65+ years and retired on Social Security<br />65+ years and retired on Railroad or Civil Service<br />Disabled<br />Child/adult with kidney disease<br />Kidney Donor<br />Medicare<br />
  3. 3. Medicare Part A<br />Covers hospital services<br />No Charge<br />Usually primary payer<br />Medicare Part B<br />Covers outpatient services<br />Paid for by recipient<br />Includes physician charges<br />Two types of Medicare Benefits<br />
  4. 4. Benefit period starts when the patient is admitted and ends when the patient has not been in an acute care hospital or nursing home bed for 60 consecutive days<br />Will pay for up to 100 days of skilled care<br />Must have had at least a 3 day stay at a hospital<br />Medicare Part A: Hospital Benefits<br />
  5. 5. Supplemental medical insurance<br />Patient has to pay a premium<br />Medicare Part B: Medical & Preventative Care Benefits<br />
  6. 6. Medicare Part C<br />Benefits are paid monthly <br />Covers both A & B services<br />Medicare Part D<br />Covers prescription drugs<br />Additional Medicare Coverage<br />
  7. 7. Railroad Retirement Benefits<br />Employed Elderly Benefits<br />Medicare/Medicaid<br />Medicare/Medigap<br />Managed Care plans<br />Additional Medicare Coverage Continued<br />
  8. 8. Risk plan<br />Only receive Medicare covered services from provider who are contracted member of HMO network – restricted beneficiaries<br />Cost Plan<br />Receive Medicare covered services from providers outside of the HMO network – unrestricted beneficiaries<br />Medicare Managed Care Plans<br />
  9. 9. Quality Improvement Organization<br />Federal False Claims Amendment Act<br />Health Insurance Portability and Accountability Act<br />Civil Monetary Penalties Law<br />Stark I and II Regulations <br />Clinical Laboratory Improvement Amendment<br />Utilization and Quality Control<br />
  10. 10. Payment Fundamentals<br />Participating<br />Non-Participating<br />
  11. 11. Establish medical necessity<br />Substantiate why patient needs service<br />Prepayment screens<br />PRIOR AUTHORIZATION<br />
  12. 12. DRGs<br />HCPCS<br />CPT<br />RBRVS<br />Medicare Reimbursement<br />
  13. 13. Fiscal intermediaries/MACs<br />National Provider Identifier (NPI)<br />Signature on File (SOF)<br />Electronic submission<br />Cross over claims<br />Claim Submission<br />
  14. 14. Explanation of Benefits (EOB)<br />After Claim Submission<br />

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