1. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1 Chapter 12 Medicare Insurance Handbook for the Medical Office 13 th edition

2. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Introduction to Medicare 1. Explain eligibility criteria for Medicare. 2. Name important information to abstract from a patient’s Medicare card. 3. Identify the benefits and nonbenefits of Medicare. 4. List five federal laws adopted to increase health benefits for employed elderly individuals. 5. Explain various Medicare and other insurance coverage combinations. 2 Lesson 12.1

3. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Introduction to Medicare (cont’d) 6. Differentiate between an HMO risk plan and an HMO cost plan. 7. Name the conditions when an HMO-Medicare patient can be seen by a nonmember HMO physician. 8. Name the federal program that relates to utilization and quality control of health services. 9. State the name of the federal act applicable to reducing fraud and abuse. 3 Lesson 12.1

4. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Policies and Regulations  Centers for Medicare and Medicaid Services (CMS) Divisions  Center for Medicare Management  Center for Beneficiary Choices  Center for Medicaid and State Operations 4

5. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Eligibility Requirements  People 65+ who are retired on Social Security  People 65+ who are retired from railroad or civil service  Disabled  Children and adults with kidney disease  Kidney donors 5

6. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Health Insurance Card 6

7. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicare Part A: Hospital Benefits  Hospital up to 90 days  Nursing facility up to 100 days  Home healthcare services  Psychiatric hospital  Hospice care  Respite care 7

8. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicare Part B: Medical and Preventive Care Benefits  Medical expenses  Clinical laboratory services  Home health care  Outpatient hospital care  Blood 8

9. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicare Part C: Medicare Advantage Plan  Available plans:  HMO  POS  PPO  PFFS  PSO  RFBS  MSA 9

10. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicare Part D  Prescription drug benefit  Effective January 1, 2006  Eligible Medicaid/Medicare member pays no premium or deductible  Tiered drug plan  Check Medicare information for authorization requirements 10

11. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Railroad Retirement Benefits  Medical insurance premiums automatically deducted  Entitled to benefits for covered services at a qualified American facility  Some may be member of  Railroad hospital association  Prepayment plans  Contracts with Medicare 11

12. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Employed Elderly Benefits  Federal laws and regulations:  Omnibus Budget Reconciliation Act (OBRA)  Tax Equity and Fiscal Responsibility Act (TEFRA)  Deficit Reduction Act (DEFRA)  Consolidated Omnibus Budget Reconciliation Act (COBRA)  Tax Reform Act 12

13. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Additional Insurance Programs  Determining if Medicare is primary or secondary  Ask about other insurance  Copy Medicare card  Ask about supplemental coverage  Call the carrier  Bill correctly 13

14. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicare Managed Care Plans  Health Maintenance Organizations  Risk plan  Cost plan  Carrier dealing prepayment organization 14

15. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicare Managed Care Plans  Risk plan  Beneficiaries receive Medicare-covered services from providers who are contracted members of HMO network  Enrollees called restricted beneficiaries  Cost plan  Beneficiaries received Medicare-covered services from sources in and outside of the HMO network  Enrollees calls unrestricted beneficiaries 15

16. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Utilization and Quality Control  Quality Improvement Organizations  Contracts with CMS to review: Medical necessity Reasonableness Appropriateness Completeness and adequacy of care 16

17. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Utilization and Quality Control  Federal False Claims Amendment Act  Clinical Laboratory Improvement Amendments 17

18. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicare Claims Submission 10. State the benefits for a participating versus nonparticipating physician. 11. Explain when to obtain a patient’s signature on an Advance Beneficiary Notice of Noncoverage or waiver of liability agreement. 12. Define a Medicare-mandated prepayment screen. 13. Explain the resource-based relative value scale system Medicare uses for establishing fees. 14. List situations for obtaining an annual patient’s signature authorization. 18 Lesson 12.2

19. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicare Claims Submission (Cont’d) 15. Determine the time limit requirements for transmitting a Medicare claim. 16. Explain claims submission for individuals who have Medicare with other insurance. 17. List CMS-1500 (02-12) block numbers that require Medigap information when transmitting a Medicare/Medigap claim. 18. State the components of a Medicare remittance advice. 19. Post information on the patient’s financial accounting record after a Medicare payment has been received. 19 Lesson 12.2

20. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Payment Fundamentals  Participating physician  Nonparticipating physician  Prior authorization 20

21. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Waiver of Liability Provision  Advance Beneficiary Notice of Noncoverage (ABN)  Have patient sign if you expect Medicare to deny payment (entirely or in part)  Refer to NCDs and LCDs to determine which services require an ABN 21

22. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Prepayment Screens  Medicare limits number of time procedure can be billed during a specific time frame  Computer screen triggers suspension of processing 22

23. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicare Reimbursement  Chronology of prospective payment system  Reasonable fee  Resource-based relative value scale  Healthcare Common Procedure Coding System  Physician Quality Reporting Initiative  Recovery Audit Contractor 23

24. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicare Reimbursement  RBRVS Formula: RVU x GAF x CF = Medicare $ per service 24

25. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Claim Submission  Local coverage determination  MACs and FIs  Provider identification numbers  Patient’s signature authorization  Time limit  Paper/electronic claims 25

26. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Patient’s Signature Authorization  Signatures must be retained  Called “Signature on file” or “SOF”  SOF situations: Illiterate of physically handicapped Confinement in a facility Medigap (MG) claim Deceased patient Medi-Medi claim 26

27. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Claim Submission  Medicare/Medicaid claims  Medicare/Medigap claims  Medicare/Employer supplemental insurance claims  Medicare/Supplemental and Medicare supplementary payer claims  Claims for deceased patients  Physician substitute coverage 27

28. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved After Claim Submission  Remittance advice  Medicare Summary Notice 28

29. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Beneficiary Representative/Representative Payee  Posting payments  Review and redetermination process 29

30. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Questions? 30