Survey of Medical Insurance pp ch10

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Survey of Medical Insurance pp ch10

  1. 1. 10 Medicare
  2. 2. Learning Outcomes <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>10.1 List the eligibility requirements for Medicare program coverage. </li></ul><ul><li>10.2 Describe the coverage provided by Medicare Part A, Part B, Part C, and Part D. </li></ul><ul><li>10.3 Describe medical and preventive services that are covered or excluded under Medicare Part B. </li></ul><ul><li>10.4 Review the billing rules governing Medicare participating providers. </li></ul><ul><li>10.5 Explain the calculations used to determine nonparticipating provider payments for assigned and unassigned claims under Medicare. </li></ul>10-2
  3. 3. Learning Outcomes (Continued) <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>10.6 Outline the features of the Original Medicare Plan. </li></ul><ul><li>10.7 Discuss the features and coverage offered under Medicare Advantage plans. </li></ul><ul><li>10.8 Explain the coverage that Medigap plans offer. </li></ul><ul><li>10.9 Compare the Medicare PQRI, Medical Review (MR), and RAC programs. </li></ul><ul><li>10.10 Demonstrate the ability to prepare correct Medicare primary claims. </li></ul>10-3
  4. 4. Key Terms <ul><li>advance beneficiary notice of noncoverage (ABN) </li></ul><ul><li>carrier </li></ul><ul><li>Clinical Laboratory Improvement Amendments (CLIA) </li></ul><ul><li>Common Working File (CWF) </li></ul><ul><li>fiscal intermediary </li></ul><ul><li>Health Professional Shortage Area (HPSA) </li></ul>10-4 <ul><li>incident-to services </li></ul><ul><li>initial preventive physical examination (IPPE) </li></ul><ul><li>limiting charge </li></ul><ul><li>local coverage determination (LCD) </li></ul><ul><li>Medical Review (MR) Program </li></ul><ul><li>Medical Savings Account (MSA) </li></ul><ul><li>Medicare administrative contractor (MAC) </li></ul>
  5. 5. Key Terms (Continued) <ul><li>Medicare Advantage </li></ul><ul><li>Medicare card </li></ul><ul><li>Medicare health insurance claim number (HICN) </li></ul><ul><li>Medicare Modernization Act (MMA) </li></ul><ul><li>Medicare Part A (Hospital Insurance [HI]) </li></ul><ul><li>Medicare Part B (Supplementary Medical Insurance [SMI]) </li></ul>10-5 <ul><li>Medicare Part C </li></ul><ul><li>Medicare Part D </li></ul><ul><li>Medicare Summary Notice (MSN) </li></ul><ul><li>Medigap </li></ul><ul><li>national coverage determination (NCD) </li></ul><ul><li>notifier </li></ul><ul><li>Original Medicare Plan </li></ul><ul><li>Quality Improvement Organization (QIO) </li></ul>
  6. 6. Key Terms (Continued) <ul><li>Physician Quality Reporting Initiative (PQRI) </li></ul><ul><li>roster billing </li></ul><ul><li>screening service </li></ul><ul><li>urgently needed care </li></ul><ul><li>waived tests </li></ul>10-6
  7. 7. 10.1 Eligibility for Medicare <ul><li>Individuals eligible for Medicare are in one of six categories: </li></ul><ul><ul><li>Age sixty-five or older </li></ul></ul><ul><ul><li>Disabled adults </li></ul></ul><ul><ul><li>Disabled before age eighteen </li></ul></ul><ul><ul><li>Spouses of deceased, disabled, or retired employees </li></ul></ul><ul><ul><li>Retired federal employees enrolled in the Civil Service Retirement System (CSRS) </li></ul></ul><ul><ul><li>Individuals of any age diagnosed with end-stage renal disease (ESRD) </li></ul></ul>10-7
  8. 8. 10.2 The Medicare Program <ul><li>Medicare Part A (Hospital Insurance [HI])— program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care </li></ul><ul><li>Medicare Part B (Supplementary Medical Insurance [SMI])— program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies </li></ul>10-8
  9. 9. 10.2 The Medicare Program (Continued) <ul><li>Medicare Part C— managed care health plans under the Medicare Advantage program </li></ul><ul><ul><li>Medicare Modernization Act (MMA)— law with a number of Medicare changes, including a prescription drug benefit </li></ul></ul><ul><li>Medicare Part D— voluntary Medicare prescription drug reimbursement plans </li></ul>10-9
  10. 10. 10.3 Medicare Coverage and Benefits <ul><li>Common Working File (CWF)— Medicare’s master patient/procedural database </li></ul><ul><li>Medicare card— Medicare insurance identification card received by each member </li></ul><ul><li>Medicare health insurance claim number (HICN)— Medicare beneficiary’s identification number </li></ul><ul><li>Fiscal intermediary— government contractor that processes claims </li></ul><ul><li>Carriers —health plans that process claims sent by physicians, providers, and suppliers </li></ul>10-10
  11. 11. 10.3 Medicare Coverage and Benefits (Continued) <ul><li>Medicare administrative contractor (MAC)— contractor who handles claims and related functions </li></ul><ul><li>Medicare Part B covers: </li></ul><ul><ul><li>Physician services </li></ul></ul><ul><ul><li>Diagnostic X-rays and laboratory tests </li></ul></ul><ul><ul><li>Outpatient hospital visits </li></ul></ul><ul><ul><li>Durable medical equipment </li></ul></ul><ul><ul><li>Other nonhospital services </li></ul></ul>10-11
  12. 12. 10.3 Medicare Coverage and Benefits (Continued) <ul><li>Medicare Part B does not cover: </li></ul><ul><ul><li>Most routine and custodial care </li></ul></ul><ul><ul><li>Examinations for eyeglasses or hearing aids </li></ul></ul><ul><ul><li>Some foot care procedures </li></ul></ul><ul><ul><li>Services not ordered by a physician </li></ul></ul><ul><ul><li>Cosmetic surgery </li></ul></ul><ul><ul><li>Health care received while traveling outside the United States </li></ul></ul><ul><ul><li>Procedures deemed not reasonable and medically necessary </li></ul></ul>10-12
  13. 13. 10.3 Medicare Coverage and Benefits (Continued) <ul><li>Initial preventive physical examination (IPPE)— the benefit of a preventive visit for new beneficiaries </li></ul><ul><li>Screening services— tests or procedures performed for a patient with no symptoms, abnormal findings, or relevant history </li></ul><ul><li>Excluded services and not medically necessary services are not covered under any circumstances </li></ul>10-13
  14. 14. 10.4 Medicare Participating Providers <ul><li>Participating providers agree to accept assignment for all Medicare claims and to accept Medicare’s fee as payment in full for services </li></ul><ul><ul><li>Responsible for informing patients when services will not, or are not likely to be, paid by the program </li></ul></ul><ul><ul><li>Must comply with numerous billing rules such as global periods </li></ul></ul><ul><li>Health Professional Shortage Area (HPSA)— geographical area offering participation bonuses to physicians </li></ul>10-14
  15. 15. 10.4 Medicare Participating Providers (Continued) <ul><li>Advance beneficiary notice of noncoverage (ABN)— form used to inform patients that a service is not likely to be reimbursed </li></ul><ul><li>Local coverage determination (LCD)— notices sent to physicians with information about the coding and medical necessity of a service </li></ul><ul><li>National coverage determination (NCD)— policy stating whether and under what circumstances a service is covered   </li></ul><ul><li>Notifier— provider who completes the header on an ABN </li></ul>10-15
  16. 16. 10.5 Nonparticipating Providers <ul><li>Nonparticipating providers choose whether to accept assignments on a claim-by-claim basis </li></ul><ul><ul><li>NonPAR providers are allowed 5 percent less than PAR providers on assigned claims </li></ul></ul><ul><ul><li>On unassigned claims, nonPAR providers are subject to Medicare’s limiting charges </li></ul></ul><ul><li>Limiting charge— highest fee nonparticipating physicians may charge for a particular service </li></ul>10-16
  17. 17. 10.6 Original Medicare Plan <ul><li>The Original Medicare Plan is a fee-for-service plan that provides maximum freedom of choice when selecting a provider or specialist </li></ul><ul><ul><li>Patients are responsible for an annual deductible and a small portion of the bills </li></ul></ul><ul><ul><li>Patients receive a Medicare Summary Notice (MSN)— remittance advice from Medicare to beneficiaries detailing their services and charges </li></ul></ul>10-17
  18. 18. 10.7 Medicare Advantage Plans <ul><li>Medicare Advantage— group of managed care plans other than the Original Medicare Plan </li></ul><ul><li>Medicare Advantage offers three major types of plans: </li></ul><ul><li>1. Medicare coordinated care plans (CCPs) </li></ul><ul><li>2. Medicare private fee-for-service plans </li></ul><ul><li>3. Medical Savings Accounts (MSAs)— Medicare health savings account program </li></ul><ul><li>Urgently needed care— beneficiary’s unexpected illness or injury requiring immediate treatment </li></ul>10-18
  19. 19. 10.8 Medigap Insurance <ul><li>Medigap— plan offered by a private insurance carrier to supplement coverage </li></ul><ul><ul><li>Pays for services not covered by Medicare </li></ul></ul><ul><ul><li>Coverage varies, but all provide coverage for patient deductibles and coinsurance </li></ul></ul><ul><ul><li>Some also cover excluded services such as prescription drugs and limited preventive care </li></ul></ul>10-19
  20. 20. 10.9 Medicare Billing and Compliance <ul><li>Physician Quality Reporting Initiative (PQRI)— voluntary reporting program in which physicians or other professionals collect and report their practice data </li></ul><ul><ul><li>Goal is to determine best practices, define measures, support involvement, and improve systems </li></ul></ul><ul><li>Medical Review (MR) Program— payer’s procedures for ensuring patients are given appropriate care in a cost-effective manner </li></ul><ul><li>The Medicare Recovery Audit Contractor (RAC) program aims to ensure that claims paid by the MACs are correct </li></ul>10-20
  21. 21. 10.9 Medicare Billing and Compliance (Continued) <ul><li>Quality Improvement Organization (QIO)— group of physicians paid by the government to review the Medicare program </li></ul><ul><li>Clinical Laboratory Improvement Amendments (CLIA)— law establishing standards for laboratory testing </li></ul><ul><li>Waived tests— low-risk laboratory tests that physicians perform in their offices </li></ul>10-21
  22. 22. 10.9 Medicare Billing and Compliance (Continued) <ul><li>Incident to— services of allied health professionals provided under the physician’s direct supervision that may be billed under Medicare </li></ul><ul><li>Roster billing— simplified billing for vaccines </li></ul>10-22
  23. 23. 10.10 Preparing Primary Medicare Claims <ul><li>Electronic claims are faster than paper claims </li></ul><ul><li>Medical insurance specialists must be aware of the required data elements when submitting Medicare claims </li></ul>10-23

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