Chapter 11 Medicare Medical Billing

1. Chapter 11 Medicare Medical Billing

2. Medicare Administration • Centers for Medicare and Medicaid Services (CMS) • Purpose: To serve as a consolidated agency for Medicare and Medicaid • CMS and Social Security Administration (SSA)

3. Medicare Part A Eligibility • 65 or older • Adult with disability • Disabled before age of 18 • Entitled individuals’ spouses • End-stage renal disease (ESRD)

4. Medicare Part A Coverage • Inpatient hospital care: 90 days in a benefit period with 60-day lifetime reserve • Skilled nursing facility: 100 days during a benefit period • Home health care: Part time or intermittent skilled nursing care, home health aide, and therapies along with DME

5. Inpatient Benefit Days • Benefit period: Time during which medical benefits are available • Basic days: First 60 days of acute inpatient care • Coinsurance days: Days after first 60 days

6. Inpatient Benefit Days • Lifetime reserve days: Start after basic days and 30 coinsurance days in one benefit period • Skilled nursing facility days: No coinsurance for first 20 days then $124 per day for days 21 through 100 of each benefit period

7. Medicare Part B Eligibility • Meet requirements for Part A • Purchase Part A • Part B purchase: Based on annual income • Meet deductible: Yearly

8. Noncovered Services Medicare Part A and B • Routine services • Screening tests and/or screening laboratory tests • Dental care • See the full list in your student textbook, page 323.

9. Medicare Providers • Part A: Hospitals, skilled nursing facilities, nursing homes, and home health and hospice agencies • Part B: Physicians, nonphysician practitioners, or suppliers who have an agreement with Medicare.

10. Medicare Part C (Medicare + Choice) • Established in 1997: Same benefits as part A and B • Now Medicare Advantage Plus • Additional benefits: Hearing aids, dentures, and prescription drugs • Types of plans

11. Medicare Part D • Prescription drug coverage • Eligible for Parts A and B • Premium required

12. Medigap • Authorized insurance companies • Secondary payer • Not available to HMO participants • Regulated by Medicare law • Crossover: Reassignment of coverage gap to Medigap policy

13. Medical Necessity • Procedure must match diagnosis • Nonexperimental or investigational procedures • Essential treatment • Appropriate delivery level

14. Participating Providers • Contract with Medicare • Benefits

15. Nonparticipating Providers • Accepting assignment • The nonparticipating provider must still file all Medicare claims on behalf of the beneficiary, accept a 5% lower fee allowance for services, understand that Medigap/supplemental insurance does not automatically cross over, and does not have access to beneficiary eligibility information. • Not accepting assignment • Payment is sent to the beneficiary.

16. Patient’s Financial Responsibility • Par provider accepting assignment: 20% of MFS • Non-par provider accepting assignment: 20% of non-par provider’s MFS • Non-par provider not accepting assignment: Responsible for limiting charge

17. Patient Registration • Copy the Medicare card. • Obtain patient signatures. • Determine primary and secondary payers; see the extensive list on pages 333–337 of your student textbook.

18. Medicare Billing Requirements—HCPCS • Level I codes: CPT-4, procedures • Level II codes: Supplies and services and dental procedures • Level III codes: Reserved for use by regional carriers

19. Completing Medicare Part B Claim Forms • CMS-1500 (paper) • EMC (electronic) is preferred. • Information is entered into the form locators. • All forms must be accurately completed, whether using the paper CMS-1500 or EMC using a computer, modem, and approved billing software (NSF/ANSI).

20. Completing Medicare Part B Claim Forms • All paper forms are sent to Dallas, Texas. • Care must be taken to send the claim to the correct post office box for the region where the services were rendered

21. Medicare Fraud • Definition: “Knowingly and willfully executing, or attempting to execute a scheme or artifice to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program”

22. Medicare Fraud • Fraud scenarios: See student text pages 351–352.

23. Other Types of Medicare fraud • Using an incorrect or invalid provider number in order to be paid at a higher rate • Selling or sharing Medicare claim numbers in order to facilitate the filing of false claims • Waiving deductibles and/or copayments without attempts to collect such monies due or when the patient is unable to pay

24. Other Types of Medicare fraud • Falsifying information on any document filed with the government • Offering or soliciting bribes, rebates, or kickbacks

25. Medicare Abuse • Definition: “Abuse may, directly or indirectly, result in unnecessary costs to the Medicare or Medicaid program, improper payment for services which [sic] fail to meet professionally recognized standards of care, or that are medically unnecessary…” • Abuse scenarios: See student textbook page 353.

26. Protection Against Medicare Fraud and Abuse • Provider liability for fraud • Provider liability for abuse • Referring physician liability fraud/abuse • Administrative sanctions • Education and warning • Revoking assignment privileges

27. Protection Against Medicare Fraud and Abuse • Withholding payments along with recovery of overpayments • Excluding from Medicare program • Posting provider’s name on national Sanctioned Providers list

28. Chapter 12 Medicaid Medical Billing

29. Medicaid Guidelines for Each State • Establishes own eligibility standards • Determines the type, amount, duration, and scope of services • Sets rate of payment for services • Administers its own program

30. Required Eligibility Groups • Categorically needy • Medically needy • Special groups

31. Categorically Needy • Families who meet state’s aid to families with dependent children eligibility requirements as of July, 16, 1996 • Pregnant women and children under age 6: Income must be 133% under federal poverty level • Children ages 6–19 with family income up to 100% of federal poverty level.

32. Categorically Needy • Caretakers (relatives or guardians) who take care of children under the age of 18 (19 if still in high school) • SSI recipients • Persons living in medical institutions with monthly income up to 300% of SSI standard

33. Medically Needy • Persons having too much money (as in a savings account) to qualify for categorically needy • Allows states to extend eligibility to additional people

34. Medically Needy • Spend-down program: Individual is required to spend a portion of their income or resources until below, or at, state income level. • May be highly restrictive: Federal requirements designate who is to be included.

35. Special Groups • Immigrants: Eligibility is determined at federal level. • Temporary Assistance for Needy Families (TANF): Eligibility is determined at the county level.

36. Special Groups • State Children’s Health insurance Program (SCHIP): Provides more federal funds to expand Medicaid eligibility to include more uninsured children

37. Medicaid Services Mandated by the Federal Government • Inpatient services • Outpatient services • Prenatal care • Vaccines for children • Physician services • Nursing facility services for persons 21 years of age and older

38. Medicaid Services Mandated by the Federal Government • Family planning services and supplies • Rural health clinic services • Home health care for persons eligible for skilled nursing services • Laboratory and x-ray services • Pediatric and family nurse practioner services • Nurse midwife services

39. Medicaid Services Mandated by the Federal Government • Federally Qualified Health Center (FQHC) • Early and periodic screening, diagnostic, and treatment services for children under 21 years of age (EPSDT)

40. Optional Medicaid Services • Diagnostic services • Clinic services • Intermediate care facilities for people with mental retardation

41. PACE (Programs of All-inclusive Care for the Elderly) • Provides an alternative to institutional care for persons age 55 or older who require a nursing facility level of care. • Offers and manages all health, medical, and social services

42. PACE (Programs of All-inclusive Care for the Elderly) • Mobilizes other services: Preventative, rehabilitative, curative, and supportive care • Care is provided in day health centers, hospitals, and nursing homes.

43. Amount and Duration of Medicaid Services • State may impose limitations. • Limitations are restricted by federal guidelines.

44. Medicaid Verification • Always verify patient status prior to seeing the physician • Some electronic verification available • Check for restricted status, which requires the patient to see a specific physician (e.g., PCP) and/or pharmacy.

45. Medicaid Claims Filing • Time limits for submitting claims • Claims must be submitted within 95 days from each date of service (DOS). • Appeal time limits • All appeals of denied claims and requests for adjustments must be received within 180 days from the date of disposition, the date of the Remittance and Status (R&S) report on which that claim appears

46. Medicaid Claims Filing • Claims with incomplete information and zero paid claims • Claims lacking the information necessary for processing are listed on the R&S report with an explanation of benefits (EOB) code requesting the missing information

47. Medicaid Claims Filing • Newborn claim hints • When filing a claim for a newborn, if the mother’s name is “Jane Jones,” use “Boy Jane Jones” for a male child and a “Girl Jane Jones” for a female child. Do not use “NBM” for newborn male or “NMF” for newborn female

48. Chapter 13 TRICARE Medical Billing

49. TRICARE Eligibility • Sponsor: Member of military • Beneficiary: Family members of member of military • Service/military retiree: Retired military service member • Uniformed sponsors and family members must register with DEERS.

50. TRICARE Eligibility • A military retiree may remain in TRICARE until age 65. • CHAMPVA beneficiaries are not eligible for TRICARE.