Chapter 12

Medicare

Email- ksweet@kaplan.edu Seminars are held on Sundays

from9PM – 10PM EST

AIM- KiSweet97 during my office hours on Sunday 8PM-9PM EST or you can make an appointment.

Communication with Me“Remember I am here to Help”

•In seminar, you can messenger meprivately by clicking on my name at theleft hand side of the seminar screen. I haveturned off the ability for you to messengerother students privately, as that seems tobe distracting. You can always email otherstudents and ask for their AIM names sothat you can contact each other.

Final Project Due Unit 9 Training for Staff Members This final project is due in Unit 9 but

you will want to get started on it early so you can do a great job.

One great way to learn something new is to teach it to somebody else. Over the course of this class, you will build a PowerPoint presentation that is minimum of 27 slides outlining the major concepts every billing specialist should know.

For the Final Project due in Unit 9, you will be completing a training that outlines some basics .

Final Project (Cont’d)1. Develop an in-service training session for new billing

specialists that covers the concepts you are learning in this course;

2. You should dedicate at least 3 slides outlining these concepts: legal aspects of insurance billing, health insurance concepts, CMS-1500 forms, UB-04 forms, Blue Cross/Blue Shield, Medicare, Medicaid, and TRICARE and CHAMPVA. There should be a minimum of 27 slides.

3. Use the Note section as needed to explain terms, concepts, and definitions that you would cover if you were teaching this training

Resources that can help you: Websites found in Extra! Extra! in each unit. eText key terms and review questions.

This project will be due in Unit 9 and submitted to the Dropbox.

Medicare Federal health insurance program

The largest health insurance program Created in 1965 Managed by CMS

MedicareMedicare Part A

Care received in hospitals and skilled nursing facilities, home and hospice care

Usually premium-free May enroll in Medicare Part B

Medicare Part B Physician services, outpatient hospital care,

other medical services Monthly fee or premium

MedicareEnrollment may be automatic or by

applicationLow-income beneficiaries may be

eligible for additional programs QMB SLMB QI

Individuals enrolled receive ID cards

Medicare The Medicare insurance program is

constantly changing Current Medicare information is available

At a local Social Security office At the CMS web site At the Medicare web site

Medicare Part A Covered services

Hospital stays Skilled nursing facility Home health care Hospice care

Medicare Part A Deductibles and copayments

Inpatient hospital care Up to 60 days: $900 deductible 61-150 days: beneficiary pays daily copays After 150 days: beneficiary pays all charges

Skilled nursing facility Up to 20 days: no charges 21-100 days: beneficiary pays daily copays After 100 days: beneficiary pays all charges

Medicare Part A Deductibles and copays

Home health care No deductible Beneficiary is responsible for 20% of the

Medicare approved amount for DME

Medicare Part A Challenges

Maintaining a professional and compassionate attitude

Keeping up with changes related to covered services, deductibles, and copays

Medicare Part B Required to pay for services and

supplies which are: Reasonable Medically necessary Consistent with patient’s diagnosis

Defrays cost of diagnostic, treatment, and preventative health care services

Medicare Part B Advanced Beneficiary Notice

agreements Services the provider believes are

necessary, but not covered by Medicare ABN must be signed before the service is

performed

Medicare Part B Participating providers (PAR)

Contract with Medicare Agree to accept Medicare approved

payment rates for services Medicare carrier remits payment to PAR Accepts assignment for Medicare patients

Medicare Part B Nonparticipating providers (NonPAR)

Not enrolled in the Medicare program Can accept assignment Subject to restrictions Patients have higher out-of-pocket

expenses Must provide a Medicare Surgical Financial

Disclosure Statement

Medicare Fee Schedule List of Medicare approved fees for

services Based on the RBRVS system

Relative value unit Geographic adjustment factor National conversion factor

Calculated on an annual basis

NCCI Financial incentive from CMS to ensure

coding accuracy Goals

To promote provider compliance with Medicare diagnosis and procedure coding guidelines

To ensure payment for provider services

NCCI Claims are edited by an electronic

screening process Edit process verifies:

The patient is a Medicare beneficiary All deductibles and copays have been met Medicare is the primary payer Diagnosis and procedure codes are

correct

NCCI NCCI edits identify:

Mutually exclusive procedures Component part coding Unbundling Invalid modifiers

When errors occur, the provider is notified

Claim Submission General information

CMS-1500 form Filing deadline is 12/31 of the year

following the date of service All providers must submit Medicare claims

for their patients Insurance carriers for Medicare claims are

selected by CMS through a bidding process

Medicare as Primary Payer Medicare is the primary payer for nearly

all provider services Conditional primary payer status

Reinforcement Exercise The _________________ form is used for all

Medicare claims

The deadline for filing a Medicare claim is ____________________.

Supplemental Insurance Medigap Employer-sponsored Medicare

supplemental health insurance Medicare-Medicaid crossover program

Medicare as Secondary Payer All primary payers must be billed before

Medicare claims are submitted Attach a copy of the primary payer’s

EOB to the Medicare claim form

Other Medicare Plan Choices Medicare Advantage

Plans Medicare Managed

Care Plans Medicare PPO Medicare Private Fee-

for-Service Plans Medicare Specialty

Plans Medicare Savings

Account Plan

Beneficiary must: Be enrolled in

Medicare Part A and B Continue to pay the

premium for Part B Not qualify for

programs related to special conditions

Processing Medicare Payments PARs receive payments directly, on a

regular basis Payments are not claim-specific Payment information is posted to each

patient’s account

Looking Ahead Read Chapter 13

Chapter 13 will discuss Medicaid. Participate in Discussion

In Unit 7 Discussion, you will be talking about Medicaid forms.10 Points

Attend the Weekly Seminar or Complete Option 2 The weekly Seminar will address topics in this unit.15 Points

Complete Unit 7 Assignment In the Unit 7 Assignment, you will be comparing Medicaid with private or commercial insurance companies.40 Points

Complete Unit 7 Quiz This quiz will cover concepts learned in this unit.30 Points

Questions