chapter 11 medicare medical billing

Comprehensive Health Insurance

Billing, Coding, and Reimbursement

Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458

All rights reserved.

Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

Chapter 11Medicare Medical Billing




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)




Medicare Part A Eligibility

65 or older Adult with disability Disabled before age of 18 Entitled individuals’ spouses End-stage renal disease (ESRD)




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




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




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




Medicare Part B Eligibility

Meet requirements for Part A Purchase Part A Part B purchase: Based on annual income Meet deductible: Yearly




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.




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.




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




Medicare Part D

Prescription drug coverage Eligible for Parts A and B Premium required




Medigap

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

to Medigap policy




Medical Necessity

Procedure must match diagnosis Nonexperimental or investigational

procedures Essential treatment Appropriate delivery level




Participating Providers

Contract with Medicare Benefits




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.




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




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.




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




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).




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




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”




Medicare Fraud

Fraud scenarios: See student text pages 351–352.




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




Other Types of Medicare fraud

Falsifying information on any document filed with the government

Offering or soliciting bribes, rebates, or kickbacks




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.




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




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






Chapter 12Medicaid Medical Billing




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




Required Eligibility Groups

Categorically needy Medically needy Special groups




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.




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




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




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.




Special Groups

Immigrants: Eligibility is determined at federal level.

Temporary Assistance for Needy Families (TANF): Eligibility is determined at the county level.




Special Groups

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




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





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





Federally Qualified Health Center (FQHC) Early and periodic screening, diagnostic,

and treatment services for children under 21 years of age (EPSDT)




Optional Medicaid Services

Diagnostic services Clinic services Intermediate care facilities for people with

mental retardation




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




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.




Amount and Duration of Medicaid Services

State may impose limitations. Limitations are restricted by federal

guidelines.




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.




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





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





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






Chapter 13TRICARE Medical Billing




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.




TRICARE Eligibility

A military retiree may remain in TRICARE until age 65.

CHAMPVA beneficiaries are not eligible for TRICARE.




TRICARE Health Plans

TRICARE Standard TRICARE Prime TRICARE Prime Remote TRICAE Extra TRICARE Senior Prime




TRICARE Standard

Fee for service program Annual deductible Covers medical services provided by a

civilian physician Expenses are shared between TRICARE

and the beneficiary. Catastrophic cap




TRICARE Prime

Managed care plan Offers additional preventive care Requires enrollment Primary care manager Priority at MTF




TRICARE Prime Remote

For active duty members not assigned close to an MTF

Available to family members Same as TRICARE Prime




TRICARE Extra

Alternative managed care plan for individuals not having priority at an MTF

Active duty not eligible More expensive than Prime, less

expensive than Standard Annual deductible




TRICARE Senior Prime

Age 65 Prescription drug benefit Must be enrolled in Medicare Part A and B No enrollment fee Second payer to Medicare Primary payer if not covered by Medicare




CHAMPVA

Administered by the Department of Veterans Affairs

Veterans with 100% service-related disabilities

Spouse is eligible. All services must be approved. Last payer after all insurance and

Medicare




Submitting Claims

The physician must file a paper claim using the CMS-1500.

The hospital, clinic, or outpatient facility must file a UB-04.




Submitting Claims

All claims must include the following information:– Patient’s name as it appears on his or her

military ID card– Sponsor’s Social Security number (SSN)– Patient’s date of birth




Submitting Claims

Other health insurance (OHI) information Appropriate HCPCS, CPT, and ICD-9

codes on CMS-1500 claim forms Appropriate HCPCS, CPT, ICD-9, and

revenue codes on UB-04 claim forms Admitting diagnosis on UB-04 claim forms Care approval number, if applicable Provider’s tax ID number or SSN




Submitting Claims

Referring physician Rendering physician Beneficiary’s signature (or indicate

“signature on file” if the beneficiary’s signature is on a “release of information” document)

The provider’s or representative’s signature.




Wisconsin Physicians Service (WPS)

Payer for TRICARE Senior Prime Provider submits claim first After adjudication, claim is sent to WPS.




Claims for CHAMPVA

Sent electronically through the VA’s clearing house, Emdeon Envoy

Paper claims are submitted to VA Facility Fee Department that authorized the claim.

Paper claims may also be sent to: VA Health Administration Center CHAMPVA, P.O. BOX 65024, Denver, CO 80206–9024.




Claims for Northern Region of United States

Health Net Federal Services, Inc., Care of Palmetto Government Benefits Administrators (PGBA)

PGBA provides online claims service.




Advantages of Filing Online

Direct transmission to PGBA Immediate acceptance or rejection of

claim Time saving online corrections of claims Processing and payment in a shorter

period of time

chapter 11 medicare medical billing

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