medicare 101

MEDICARE 101 Part 1: Introduction to Medicare Part B

Provider Outreach & Education – January 8, 2014

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DISCLAIMER

This resource is not a legal document. This presentation was prepared as a tool to assist our providers. This presentation was current at the time it was created. Although, every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Reproduction of this material for profit is prohibited. 

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Agenda

Medicare Basics

Types of Medicare

Part B Providers

Part B Helpful Hints

Medicare Appeals

Cahaba GBA Website Self-Service Tools

Online Polling

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MEDICARE BASICS

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Inception of Medicare1965 – Medicare signed into law by President Lyndon B. Johnson

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Key Medicare Administrators

Congress Department of Health and Human Services (HHS) Social Security Administration (SSA) Centers for Medicare and Medicaid Services (CMS) Office of the Inspector General (OIG)

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Medicare Contractors

Medicare Administrative Contractor (MAC) Beneficiary Contact Center (BCC) Coordinator of Benefits Contractor (COBC) Medicare Secondary Pay Recovery Contractor (MSPRC) Comprehensive Error Rate Testing (CERT) Recovery Auditor (RA) Zone Program Integrity Contractor (ZPIC)

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Medicare Eligibility Requirements

Qualifiers

Age 65 or Older

Disabled

End Stage Renal Disease

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65Beneficiary Eligibility based on:

65 years or older Individual/Spouse/Parent Work a minimum of 10 years Contributions to FICA US Citizen or Permanent Legal Resident

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DisabilityBeneficiary Eligibility based on:

Under the age of 65 Beneficiary is entitled to Social Security disability benefits for 24 months Beneficiary received a disability pension from the railroad retirement board and meet certain conditions Beneficiary receives Social Security disability benefits because of Lou Gehrig’s disease (amyotrophic lateral sclerosis) Beneficiary worked long enough in a government job where Medicare taxes were paid and is entitled to Social Security disability benefits for 24 months

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End Stage Renal Disease (ESRD)

Beneficiary Eligibility based on:

Any Age Diagnosed with ESRD:

Receiving Dialysis Kidney Transplant Recipient

http://cms.gov/Center/Special-Topic/End-Stage-Renal-Disease-ESRD-Center.html?redirect=/center/esrd.asp

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Identifying the Medicare Beneficiary

Red, White, and Blue Card Name Health Insurance Claim Number (HICN) Sex Type of Entitlement Effective Date

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Medicare Beneficiary Identification Tips

Ask patients for insurance cards instead of Medicare Card Recommend making copies of all insurance cards presented Update patient information annually, preferably after open enrollment ends Check the effective dates on the coverage types, they are not always the same Enter the patients name exactly on the claim as it appears on the patients Medicare card

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TYPES OF MEDICARE

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Part A

Covers: Inpatient Care in Hospitals

Inpatient Care in a Skilled Nursing Facility

Hospice

Home Health Services

Inpatient Care in a Religious Nonmedical Healthcare Institution

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Part B

Covers: Physicians Services

Outpatient Care

Durable Medical Equipment

Other Medical Services

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Part C

Offers: Part A & B Coverage Combination

May offer extra coverage

Most included Medicare Prescription drug coverage

Claims are processed by private insurance companies

http://www.cms.gov/transmittals/downloads/R97MCM.pdf

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Part D

Available: To anyone who is eligible for Medicare Part A or B

Provided through: Prescription Drug Plans Other Medicare Health Plans Retiree Employers and Union Plans

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PART B PROVIDERS

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Eligible Part B Providers

PHYSICIANS NON- PHYSICIAN PRACTITIONERS*

SUPPLIERS*

Doctors of Medicine (MD) or Osteopathy (DO)

Physician Assistant (PA) Ambulance

Dental Surgery Nurse Practitioner (NP) Ambulatory Surgical Center (ASC)

Chiropractor (DC) Clinical Nurse Specialist (CNS)

Independent Diagnostic Testing Facility (IDTF)

Podiatry Clinical Psychologist (CP) Independent Lab

Optometry Registered Dietician Mammography Center

*This is not an all-inclusive list

Provider Enrollment

Paper Applications:

CMS 855B--Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers CMS 855I --Medicare Enrollment Application for Physicians and Non-Physician Practitioners CMS 855R--Medicare Enrollment Application for Reassignment of Medicare Benefits CMS 855O--Medicare Enrollment Application for Eligible Ordering and Referring Physicians and Non-physician Practitioners CMS 855S--Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications.html

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Provider Enrollment

Online Provider Enrollment

Provider Enrollment, Chain, and Ownership System

(PECOS) allows: New/Revalidation/Update Enrollment Applications Submit Related Documentation Electronic Signatures

https://pecos.cms.hhs.gov

Provider Enrollment

Electronic Funds Transfer (EFT) Authorization Agreement CMS 588 Form Signature required by authorized official

Providers initially enrolling in the Medicare program Providers enrolled in Medicare but not receiving EFT payments and making changes in your enrollment Revalidation -providers and suppliers that were enrolled prior to March 25, 2011

http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS588.pdf

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Provider Participation

Participating

Agrees to accept assignment of Medicare benefits

Will accept Medicare’s allowable in full Payment is made to the provider Collects deductible, co-insurance and

excluded services from patient Allowance five percent higher of

Physician Fee Schedule Included in Medpard directory Automatic Medigap crossover

Non-Participating

Does not agree to accept assignment of Medicare benefits

Payment is made to the Medicare beneficiary

Allowable based on five percent less of Physician Fee Schedule

Cannot charge patient more than the 115% limiting charge

Medigap is not auto crossover Can accept assignment on case by case

but allowed non-participating allowable

Medicare Physician Fee Schedule

Used by physicians and non-physician practitioners

Pays 80% of the allowed amount for most services

Other fee schedules include:

Ambulance

Clinical Lab

Ambulatory Surgical Center

Drugs and Biologicals http://www.cahabagba.com/part-b/claims-2/fee-schedules/2014-fee-schedules/

Medicare Physician Fee Schedule

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html/

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Medicare Physician Fee Schedule

http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

CMS SearchablePhysician Fee Schedule

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PART B HELPFUL HINTS

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2014 Medicare Part B Rates

2014 Part B Deductible: $147.00

2014 Therapy Cap: $1920.00Therapy Cap includes: physical therapy and speech-language pathology combined and for occupational therapy

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Contacting Cahaba GBA

Interactive Voice Response SystemClaim StatusEligibility informationOrder Remittance AdviceUnlimited Check Amounts

Provider AuthenticationContractor/Carrier assigned Provider Transaction Access Number (PTAN)National Provider Identifier (NPI)Last five digits of your Tax Identification Number

http://www.cahabagba.com/contact-us/

1-877-567-7271

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Provider Call Tips Have your provider information, be ready to provide the physician’s PTAN/NPI/Last 5 Digits of Tax ID Beneficiary Information as listed on the Medicare Card, Health Information Number and Exact Name If calling concerning a claim denial, be ready to provide the reason for the denial as listed on the Remittance Advice If calling concerning a claims denial, be ready to provide the dollar amount of the claims billed If calling concerning a particular payment, be ready to provide the Remittance Advice Number Request your call reference number Example: GINQ-0000000

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Railroad Medicare

Railroad Medicare Claims & Inquiries contact:Palmetto GBA IVR 877-288-7600 PCC 888-355-9165

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DMEPOS

Jurisdiction C Durable Medical Equipment, Prosthetics, Orthotics, and SuppliesClaims & Inquiries contact:CGS IVR 866-238-9650 CSR 866-270-4909

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Home Health & Hospice

Jurisdiction C Home Health & HospiceClaims & Inquiries contact:Palmetto GBA IVR 866-238-9650 CSR 866-270-4909

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MEDICARE APPEALS

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Medicare Appeal Levels

RedeterminationReviewed byCahaba GBA

120 DaysTo File

No AIC

1 Reconsideration

180 DaysTo File

No AIC

2 AdministrativeLawJudge (ALJ)

60 Days To File

$140AIC

3 Medicare Appeals Council

60 DaysTo File

No AIC

4 Federal JudicialReview

560 DaysTo File

$1430AIC

*AIC – Amount in Controversy

Redetermination Submission

Paper – CMS20027 Form Fax – Redetermination Smart Form

http://www.cahabagba.com/documents/2012/02/part-b-redetermination_request_b.pdf

http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms20027.pdf

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CAHABA GBA WEBSITE

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Cahaba GBA Website

http://www.cahabagba.com/

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Claims Issue Log

http://www.cahabagba.com/part-b/claims-2/claims-issue-log/

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Claims Submission Errors

http://www.cahabagba.com/part-b/claims-2/claims-submission-issues-and-tips-to-prevent-denials/

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Provider Education

http://www.cahabagba.com/part-b/education/

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Calendar of Events

https://apps.cahabagba.com/apps/course_registration/al/calendar.jsp

Date Seminar Type

01-08-2014 Medicare 101 Series: Part 1-"Introduction to Medicare Part B" Webinar

01-15-2014 Medicare 101 Series: Part 2-"The Part B Appeals Process"

01-22-2014 Medicare 101 Series: Part 3-"ICD-10"<BR< a> Webinar

01-29-2014 Medicare 101 Series: Part 4-"The Procedural Coding System"

01-30-2014 The Comprehensive Error Rate Testing (CERT) Program 02-06-2014 Medical Review: "The Probe Review Process"

Coming Soon!Webinar

02-13-2014 "The Basics of Modifiers"Coming Soon! Webinar

02-26-2014 Completing the CMS 1500 Form: "Recent Change" Coming Soon!Webinar

03-05-2014 Navigating the Cahaba GBA Website: "The Favorites" Coming Soon!Webinar

03-12-2014 Navigating the CMS Website: "The Bookmarks" Coming Soon!Webinar

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FORESEE Survey

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ONLINE POLLING

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Live ~ Post Presentation Polling

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RESOURCES

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ResourcesCahaba GBA Websitehttps://www.cahabagba.com/

Centers for Medicare and Medicaid Services http://www.cms.gov/

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Provider Contact Center   1 (877) 567-7271

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