1. Chapter 9
Medicare

2. Medicare Federal program Managed by CMS under DHHS
Primarily for retired over 65
Who pays for Medicare?

3. Eligible People 65 or older who have paid in Disabled adults on SS
Disabled under age of 18 meeting SS requirements
Retired Civil Service Retirement System employees and spouses
End-stage renal disease patients

4. Medicare Part A (automatic)
Hospital insurance for SS beneficiaries 65+
Inpatient hospital
Skilled nursing facility
Home healthcare
Hospice
Those 65+ not eligible for SS may pay premium for coverage

5. Medicare Part B (must enroll) Voluntary
Supplemental Medical Insurance
Outpatient hospital
Physician services
Medical equipment and supplies
Eligible people must enroll—voluntary
Monthly premium based on SS income.
Deductible and coinsurance (established by federal law)

6. Medicare Part C (combo deal) Voluntary
Managed care plan
Combines Parts A and B
Better benefits and lower prices than previous “Choice” plan

7. Medicare Part D (prescriptions) Voluntary
Premiums paid for discount drug prices
Covers only drugs on their list
Usually use generic drugs

8. HCIN Medicare’s health insurance claim number
Nine digits with an alpha suffix
Suffix indicates how coverage was earned

9. Benefits Medical Services—deductible, 20% coinsurance
Preventive—fully covered
Lab services—fully covered
Home healthcare—fully covered and 20% DME
Outpatient hospital—variable coinsurance
Blood—first 3 pints covered—20% of rest

10. Considered Not Medically Necessary
Routine physical exams
Dental
Eye
Hearing aid exams
Long-term care
Cosmetic surgery
Some foot care

11. Participating Providers
Agree to participate or opt out during enrollment periods
Must accept assignment
Cannot balance bill
File claims for patients
Learn Medicare rule (their manual is online)
Providers apply to participate

12. Medicare Administrative Contractors
MACs
Process Medicare claims
Act as the insurance carrier
Offer incentives to PARs

13. Incentives for PARs Higher payment than for nonPAR
MAC forwards to secondary carriers
Financial incentives for
Quality reporting
E-prescriptions
Implementing an EHR
Primary care practices

14. Modifiers used with CPT code to show ABN was signed
Payments and Coverage
Use Medicare Fee Schedule (based on RVUs)
Mandatory ABN
Services not covered by Medicare because determined not necessary
Voluntary ABN
Services determined as excluded by Medicare
Modifiers used with CPT code to show ABN was signed

15. NonPARs Paid 5% less for services
Provide voluntary ABN for noncovered services
nonPAR can either accept or not accept assigment
NonPAR Not Accepting Assignment
Limiting Charges
Collect no more than 115% of Medicare fee

16. Limiting Charge
Most a nonPAR (not accepting assignment) can charge a Medicare patient
May have patient pay for services, then bill Medicare

17. Differences in Fees Collected
PAR—Medicare’s PAR standard fee (80/20)
nonPAR accepts assignment—Medicare’s nonPAR fee (5% less than PAR) (80/20)
nonPAR does not accept assignment—Medicare’s nonPAR fee (5% less than PAR)
Medicare pays 80% of nonPAR fee, patient pays difference between nonPAR fee and limiting fee

18. Thinking It Through 9.5

19. Medicare Fee For Service
Choose any Medicare approved doctor
Responsible for
Annual deductible
Coinsurance
Noncovered Services
Patients receive Medicare Summary Notice (EOB)

20. Medicare Advantage Managed care
Provide all Medicare-approved care except hospice
Capitated payments
Referrals
Patients pay deductible, copay, coinsurance

21. GAP Plans Additional insurance offered by private payer
Used to fill in the “gap” and cover patient’s portions (copay, deductible, coinsurance)
Coordinate with Medicare
MACs processes claims for Medicare and sends to GAP plan

22. Supplemental Plan Additional coverage to Medicare B
Usually from a previous employer (retirement benefits)
Used to pay patient’s responsibility
MAC does not coordinate with supplemental plans

23. Medicare Compliance CCI (Correct Coding Initiative) Consult Codes
Use CPT codes and approved combinations
Approval list is updated each quarter
Use Medicare’s global periods (surgeries)
Consult Codes
Filing Timeline

24. Medicare’s Integrity Program
Watches for improper payments
Fraud
Abuse
Waste
Medical Review (audit system for incorrect billing)
Recovery Auditor Program (audits payments)
Zone Program Integrity Contractors (audit using data mining)

25. Duplicate Claims Billing for same procedures or equipment twice
Duplicate sent if payment didn’t come
Sending same claim to more than one MAC
If payment hasn’t come, contact MAC; don’t send another claim

26. Incident to Billing
Services provided by someone other than the doctor (assistant or nurse)
Payment will depend on the doctor’s involvement in supervising

27. Roster Billing
Medicare allows one bill for several patients receiving exact same tx if any of the patients on the list did not receive any other tx Immunizations is a good example

28. Medicare HIPAA 837P Claims
All codes listed are considered
Use a provider assignment code
Insurance type code is used when Medicare is not primary

29. Medicare CMS1500 Claims Only one claim sent if there is a GAP plan
Item 19 might be used, depending on local MAC