© 2009 Cengage Learning. All Rights Reserved. Medicare
© 2009 Cengage Learning. All Rights Reserved. Agenda Medicare coverage and eligibility Certification Payment Appeals
© 2009 Cengage Learning. All Rights Reserved. Medicare Coverage and Eligibility Part A Hospital Services Coverage SNF, HHA, hospice Eligibility Over age 65 and eligible for SSA Some disabled Funding Payroll taxes
© 2009 Cengage Learning. All Rights Reserved. Medicare Coverage and Eligibility Part B Physician Services Coverage Supplementary medical insurance Eligibility Eligible for Part A and enrolled in Part B Medicare Advantage beneficiaries Funding Premiums and co-payments
© 2009 Cengage Learning. All Rights Reserved. Medicare Coverage and Eligibility Part C Medicare Advantage Coverage Parts A, B, and D May have supplemental benefits or discounts Eligibility Eligible for Part A and enrolled in Part B Funding Trust fund May have premiums or co-pays
© 2009 Cengage Learning. All Rights Reserved. Medicare Coverage and Eligibility Part D Prescription Drugs Coverage Prescription drugs Eligibility Eligible for Part A and enrolled in Part B Medicare Advantage beneficiaries (Part C) Funding Supplementary Medical Insurance Trust Fund Premiums or co-payments
© 2009 Cengage Learning. All Rights Reserved. Miscellaneous Medicare Provisions Low Income Assistance Secondary payor rule Medigap National Coverage Decisions Advance Beneficiary Notice
© 2009 Cengage Learning. All Rights Reserved. Certification Conditions of Participation Providers Physicians and Suppliers Medicare Advantage Prescription Drug Providers
© 2009 Cengage Learning. All Rights Reserved. Medicare Payment Reimbursement Methodology Prospective Payment System (PPS) Diagnostic Related Groups (DRG) Special Adjustments Low income patients Medical education programs Outliers
© 2009 Cengage Learning. All Rights Reserved. Medicare Payment Reimbursement for Physicians Resource Based Relative Value Scale (RBRVS) HCFA Common Procedural Coding System (HCPCS) Capitation Market-Based System Assignment and Reassignment
© 2009 Cengage Learning. All Rights Reserved. Medicare Appeals Appeals by Providers, Physicians, and Other Suppliers for Parts A and B Appeals by Beneficiaries for Parts C and D