Chapter 12
Medicare
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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