medicare 101 understanding medicare final
TRANSCRIPT
MEDICARE 101: Understanding CMS
Speaker: Tara Ritter-Sellers, CPC, CPC-H, CPC-I
INTRODUCTION TO THE MEDICARE PROGRAM
CHAPTER 1
Chapter 1Pre-Assessment
33
Introduction to the Medicare Program
Largest health insurance programOver 1 billion claims annuallyOver 44 million individuals entitled
44
Identifying Beneficiaries
Health insurance card contains - Name
- Sex - Medicare Health Insurance Claim number - Date of entitlement
55
6
Medicare Card (front)
Jane Doe
Introduction to the Medicare Program
4 parts- Part A, hospital insurance- Part B, medical insurance- Part C, Medicare Advantage- Part D, prescription drug plan
77
8
You have choices in how you get your Medicare health and drug coverage
Medicare has Four Parts
Part A –Hospital Insurance
Helps cover inpatient care in hospitals and skilled nursing facilities, hospice and home health care.
Part B – Medical Insurance
Helps cover doctors’ services, outpatient care, home health care and some preventive services.
Part C – Medicare Advantage Plans
Another way to get Medicare benefits.Combines Parts A and B. Usually includes Part D coverage. Run by private insurance companies approved by and under contract with Medicare.
Part D – Medicare Prescription Drug Coverage
Helps cover the cost of prescription drugs. Run by private insurance companies approved by and under contract with Medicare.
Part AHospital InsuranceInpatient hospital careInpatient care in a Skilled Nursing Facility
following covered hospital staySome home health careHospice care
99
Part BMedical InsurancePhysician and practitioner servicesHome health careAmbulance servicesClinical laboratory and diagnostic servicesSurgical suppliesDurable medical equipment, prosthetics,
orthotics, and suppliesHospital outpatient services
1010
Medicare Part A and Part B Eligibility
Aged insuredAged uninsuredDisabled insuredEnd-Stage Renal Disease insured
1111
Part C Medicare Advantage
Organizations contract with CMS to furnish or arrange for provision of health care services to beneficiaries who- Are entitled to Part A and enrolled in Part B- Permanently reside in service area of Plan- Elect to enroll in Medicare Advantage Plan
1212
Part DPrescription Drug Plans
All who elect to enroll are covered Standard coverage or low income subsidiesHigher income people pay higher Part D premium
Modified adjusted gross income is above a certain amount
Uses same thresholds used to compute income-related adjustments to the Part B premiumAs reported on your IRS tax return from 2 years ago
Effective January 2011
13
ACASection 3308
13
Income-Related Adjustment to Part D PremiumBase beneficiary Part D premium increases
People with incomes above the thresholds used to compute income-related adjustment to Part B premiums
14
ACASection
3308
If your Yearly Income in 2009 was In 2011 You PayFile Individual Tax Return File Joint Tax Return$85,000 or below $170,000 or below Base Premium$85,001–$107,000 $170,001–$214,000 Higher premium$107,001–$160,000 $214,001–$320,000 Higher premium$160,001–$214,000 $320,001–$428,000 Higher premiumabove $214,000 above $428,000 Higher premium
Organizations ThatImpact Medicare
Social Security AdministrationOffice of Inspector GeneralQuality Improvement OrganizationsState Health Insurance Assistance Program
1515
Recent Laws That Impact Medicare
Medicare Improvements for Patients and Providers Act of 2008
Medicare, Medicaid, and State Children’s Insurance Program Extension Act of 2007
1616
Patient Protection and Affordable Care Act (PPACA)
Signed into law H.R. 3590 on March 23, 2010Makes numerous statutory changes to Medicare program
The Health Care and Education Reconciliation Act of 2010 (HCERA)
Signed into law H.R. 4872 on March 30, 2010Modifies PPACA and adds several new provisions
Together called the Affordable Care Act
17
New Legislation – Health Reform
Highlights of Affordable Care Act
Closes prescription drug coverage “Donut Hole”
Strengthens the financial health of MedicareInvests in fighting waste, fraud, and abuseWill extend the financial health of Medicare by
12 yearsChanges annual enrollment period for MA and
PDP Improves preventive services coverage
Lower costsFree annual wellness check-ups starting in 2011
18
Highlights of Affordable Care Act (continued)
Promotes better care after a hospital dischargeCreates the Center for Medicare & Medicaid
InnovationHelp for early retirees (before age 65)
Temporary program to offset cost of expensive premiums
Help for people with pre-existing conditionsHealth insurance through temporary high-risk
pools In 2014, insurance companies can’t deny
coverage
19
Highlights of Affordable Care Act (continued)
Extends dependent coverage to age 26 Eliminates limits on benefitsProvides $11B for Federally Qualified Health
CentersOutpatient primary care and preventive services“Safety net” providers
Community health centersPublic housing centersOutpatient programs funded by the Indian Health
ServicePrograms serving migrants and the homeless
20
ACA Section
1001
Let's Review
What are Medicare’s 4 parts?Medicare Part A and Part B are available to
what 4 groups of individuals?
2121
BECOMING A MEDICARE PROVIDER OR SUPPLIER
CHAPTER 2
Chapter 2Pre-Assessment
2323
Part A Providers and Suppliers
Inpatient Rehabilitation
FacilitiesLong Term Care Hospitals Rural Health ClinicsSkilled Nursing
Facilities
•Critical Access Hospitals•Federally Qualified • Health Centers•Home Health Agencies•Hospice•Hospitals (acute care inpatient)
24
Part B Providers and Suppliers
Ambulances service suppliers
Ambulatory Surgical Centers
Comprehensive Out- patient Rehabilitation Facilities
End-Stage Renal Disease Facilities
Home Health Agencies (outpatient Part B)
Hospitals (outpatient)Nurse practitionersOther non-physician
practitionersPhysiciansSkilled Nursing Facilities (outpatient)
25
Medicare PhysiciansDoctors of medicine and osteopathy, dental
surgery or dental medicine, podiatry or surgical chiropody, optometry
ChiropractorsLegally authorized to practice by State
26
Interns and Residents
Participate in approved Graduate Medical Education programs
Not in approved programs, but authorized to practice only in hospital settingAlso includes interns, residents, and fellows in
programs approved for purposes of direct Graduate Medical Education and Indirect Medical Education payments
27
Teaching Physicians
Involve residents in care of their patientsPresent during all critical or key portions of
procedure Immediately available to furnish services
during entire service
28
Practitioners
Physician assistants
Nurse practitionersClinical nurse specialistsCertified registered nurse anesthetists
Certified nurse midwives
Clinical psychologistsClinical social workersRegistered dieticians
or nutrition professionals
Legally authorized to practice by State Legally authorized to practice by State and otherwise meets Medicare and otherwise meets Medicare requirementsrequirements
29
Enrolling in MedicareObtain National Provider Identifier Complete Medicare Enrollment Application
3030
Enrolling in MedicareInclude with Medicare Enrollment Application
- Forms CMS-588 and CMS-460
- CMS Standard Electronic DataInterchange Enrollment Form
- State medical license- Occupational or business license- Certificate of Use
3131
Participating Provider/Supplier
Accepts assignmentAccept the Medicare-approved amount
As full payment for covered services Only charge Medicare deductible/coinsurance amount
They submit your claim to Medicare directlyApplies to Original Medicare Part B claimsWe say “accepts assignment”
1 year participation period
3232
Participating Provider/Supplier Benefits
Higher Medicare Physician Fee Schedule allowances Limiting charge provisions not applicable Included in Physician and Other Healthcare Professional Directory
3333
Nonparticipating Provider/Supplier
May accept assignment of claims on claim-by-claim basis
Held to limiting charge on nonassigned claimsMay collect up to the limiting charge
“Limiting Charge” means the physican can only charge you up to 15% over the Medicare-approved amount.
The limiting charge applies only to certain services and doesn’t apply to some supplies and durable medical equipment.
3434
Limiting Charge Example
MPFS Allowed Amount for Procedure “X”
Nonparticipating Provider/Supplier Allowed Amount for Procedure “X”
Limiting Charge for Procedure “X”
Beneficiary Coinsurance and Limiting Charge
PortionDue to Provider/Supplier
$200.00
$190.00
$218.50
$ 66.50
3535
Payment Amounts Example
36
Participating Provider/Supplier
NonparticipatingProvider/SupplierWho AcceptsAssignment
Nonparticipating Provider/Supplier Who Does Not Accept Assignment
Submitted $125.00 $125.00 $109.25Amount
MPFS Allowed $100.00 $ 95.00 $ 95.00Amount
80 Percent of $ 80.00 $ 76.00 $ 76.00MPFS Allowed Amount
Beneficiary $ 20.00 $ 19.00 $ 33.25Coinsurance
Total Payment $100.00 $ 95.00 $109.25 ($95.00 x 1.15To Provider/ limiting charge)Supplier
36
Cultural Competency
Addressing a patient’s social and cultural background assists in delivering high quality, effective health care
37
Let's Review
What are the steps that must be taken in order to enroll in and obtain reimbursement from Medicare?
What are the benefits of becoming a Medicare participating provider or supplier?
38
CHAPTER 3
MEDICARE REIMBURSEMENT
Chapter 3Pre-Assessment
4040
Medicare Claims
Must submit claims for services Cannot charge for completing or filing claimFile on or before December 31 of year
following year services furnished
4141
Exceptions to Mandatory FilingCertain secondary payer claims Services furnished outside the U.S.Services initially paid by third-party insurersClaims for unusual or excluded servicesClaims when provider/supplier opted out,
excluded, or debarred
4242
Electronic ClaimsClaims must be submitted electronically,
except in limited situations, using - Electronic media claims- Electronic billing software vendor or clearinghouse- Billing agent- Medicare’s free billing software
4343
Deductible, Coinsurance, and Copayment
Deductible – amount beneficiary must pay before Medicare begins to pay
Coinsurance – percentage of covered charges beneficiary may pay after meeting deductible
Copayment – amount beneficiary pays for each medical service
4444
Medicare Secondary Payer
Must determine whether Medicare is the primary or secondary payer prior to submitting a claim
Coordination of Benefits Contractor – provides assistance to providers and suppliers
4545
Incentive/Bonus Payments
Health Professional Shortage Area Incentive Payment – 10 percent
Physician Scarcity Area Bonus Payment – 5 percent
4646
Medicare Physician Fee Schedule
Basis for payment of physician services under Medicare Part B
3 components
- Relative Value Units - Conversion Factor
- Geographic Practice Cost Indices
4747
Medicare Notices
Advance Beneficiary NoticeCertificate of Medical Necessity and
Durable Medical Equipment Medicare Administrative Contractor Information Forms
Remittance AdviceMedicare Summary Notice
4848
Other Health Insurance Plans
Medicare AdvantageMedicaidMedigap
4949
Let's ReviewWhat is a Health Professional Shortage Area
incentive payment?What is the Advance Beneficiary Notice?
5050
MEDICARE PAYMENT POLICIES
CHAPTER 4
Chapter 4Pre-Assessment
5252
Medicare Covered Services
Services and supplies must be medically necessary
Proper and needed for diagnosis or treatment of medical condition
Furnished for diagnosis, direct care, treatment of medical condition
Meet standards of good medical practice Not mainly for convenienceSome Preventive Health Care Services
5353
54
Covered Preventive Services
One time “Welcome to Medicare” physical exam
Physical Exam (yearly “Wellness Exam”) Starts 2011
Abdominal aortic aneurysm screening*
Bone mass measurementCardiovascular disease
screeningsColorectal cancer
screeningsDiabetes screenings
EKG Screening*Flu shots Glaucoma testsHepatitis B shotsHIV ScreeningMammograms (screening)Pap test/pelvic
exam/clinical breast examProstate cancer screeningPneumococcal shotsSmoking cessation
*When referred during Welcome to Medicare physical exam
Health
Reform
Section
4103
Part A Inpatient Hospital Services
Bed and boardNursing and related
servicesUse of hospital or
Critical Access Hospital
facilitiesMedical social servicesDrugs, biologicals,
supplies, appliances, and equipment
Diagnostic or therapeutic services
Medical or surgical services furnished by interns or residents in training
Transportation services
5555
Part B Services
Surgery, office visits, and institutional calls
Services, supplies, and outpatient hospital services furnished incident to physician services
Outpatient physical, occupational, and speech-language pathology services
Diagnostic servicesAmbulance servicesPreventive services
5656
Incident to Physician ServicesCommonly furnished in physicians’ offices or
clinicsFurnished by physician or auxiliary personnel
under direct personal supervision of physicianFurnished without charge or included in
physician’s billIntegral, although incidental, part physician’s
professional service
57
Services not Covered by Medicare
Excluded servicesServices considered not medically necessary Services denied as bundled or included in basic
allowance of another serviceIn addition, Medicare does not pay for claims
rejected as “unprocessable”
58
Let's Review
What are medically necessary services and supplies?
What services are not covered by Medicare?
5959
EVALUATION AND MANAGEMENT
DOCUMENTATION
CHAPTER 5
Chapter 5Pre-Assessment
6161
Background – Evaluation and Management Documentation
Translates patient care work into claimsand reimbursement mechanism;
accuracyis critical inEnsuring correct payment for workSupporting correct evaluation and
management code levelProviding validation for medical review
6262
Medical Record DocumentationRecords pertinent facts, findings, and
observations about patient’s health history
Facilitates
- Evaluating and planning treatment and
monitoring treatment and health of patient- Communication and continuity of care- Claims review and payment- Utilization review and quality of care evaluations- Collection of data
6363
7 General Principles of Documentation
1. Medical record should be complete and legible
2. Each encounter should include- Reason for encounter and relevant history, physical examination findings, and prior test results- Assessment, clinical impression, or diagnosis- Plan for care- Date and legible identity of observer
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7 General Principles of Documentation
3. Rationale for ordering diagnostic tests and ancillary services should be easily inferred if not documented
4. Past and present diagnoses accessible to treating and/or consulting physician
5. Appropriate health risk factors identified
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7 General Principles of Documentation
6. Patient’s progress, response to and changes in treatment, and revision of diagnosis documented
7. CPT and ICD codes reported on health insurance claim form or billing statement supported by documentation in medical record
6666
Levels of Evaluation and Management Services
HistoryExaminationMedical decision
making
CounselingCoordination of careNature of presenting
problemTime
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3 Key Components (HEM) Procedure History Examination Medical
Decision Making Code 99201® Problem Focused Problem Focused Straightforward
99202 Expanded Expanded Straightforward Problem Focused Problem Focused
99203 Detailed Detailed Low Complexity
99204 Comprehensive Comprehensive Moderate Complexity
99205 Comprehensive Comprehensive High Complexity
CPT only copyright 2008 American Medical Association. All rights reserved.
6868
History
4 levels- Problem Focused- Expanded Problem Focused- Detailed- Comprehensive
Elements- Chief complaint- History of present
illness- Review of systems- Past, family,
and/or social history
6969
HistoryHPI ROS PFSH Level of
History
Brief N/A N/A Problem Focused
(1 – 3 elements)
Brief Problem Pertinent N/A Expanded Problem Focused
(1 – 3 elements)
Extended Extended Pertinent Detailed(4 or more elements)
Extended Complete Complete Comprehensive(4 or more elements)
Elements: ROS: PFHS areas:location, quality, constitutional, eyes, ears past historyseverity, duration, nose, mouth, throat, family historytiming, context, cardiovascular, respiratory, social historymodifying factors, gastrointestinal, gastro- associated signs urinary, musculoskeletaland symptoms integumentary, neuro-
logical, psychiatric, endocrine, hematologic/ lymphatic, allergic/ immunologic
7070
Examination
4 types- Problem Focused- Expanded Problem Focused- Detailed- Comprehensive
General multi-system or single organ system
7171
General Multi-System Examination Level of Examination Perform and Document
Problem Focused 1– 5 elements identified by a bullet in 1 or more organ system(s) or body area(s)
Expanded Problem At least 6 elements identified by a bullet in 1 orFocused more organ system(s) or body area(s)
Detailed At least 2 elements identified by a bullet fromat least 6 organ systems or body areas or atleast 12 elements identified by a bullet in 2 ormore organ systems or body areas
Comprehensive All elements identified by a bullet in at least9 organ systems or body areas; for each
system/area, at least 2 elements identified by a
bullet
7272
Single Organ System Examination
Level of Examination Perform and Document
Problem Focused 1 – 5 elements identified by bullet in box with
either shaded or unshaded border
Expanded Problem At least 6 elements identified by bullet in box
Focused with either shaded or unshaded border
Detailed At least 12 elements identified by bullet in box with either shaded or unshaded border (except
eye and psychiatric examinations)
Comprehensive Perform all elements identified by bullet in box with either shaded or unshaded border; document every element in each box with
shaded border and at least 1 element in box
with unshaded border
7373
Medical Decision Making
Straightforward Low complexity Moderate complexity High complexity
7474
Medical Decision Making
Number of Amount and/or Risk of Type of Medical
Diagnoses/ Complexity of Complications, Decision Making
Management Data to be Morbidity, and/or Options Reviewed Mortality
Minimal Minimal or None Minimal Straightforward
Limited Limited Low Low Complexity
Multiple Moderate ModerateModerate
Complexity
Extensive Extensive High High Complexity
7575
New Patient Visit
Procedure History Examination Medical Decision Making
Code 99201® Problem Focused Problem Focused
Straightforward
99202 Expanded Expanded Straightforward Problem Focused Problem Focused
99203 Detailed Detailed Low Complexity
99204 Comprehensive Comprehensive Moderate Complexity
99205 Comprehensive Comprehensive High Complexity
CPT only copyright 2008 American Medical Association. All rights reserved.
7676
Established Patient VisitProcedure History Examination Medical
Decision Code Making99211® N/A N/A N/A
99212 Problem Focused Problem Focused Straightforward
99213 Expanded Problem Expanded Problem Low Complexity Focused Focused
99214 Detailed Detailed Moderate Complexity
99215 Comprehensive Comprehensive High Complexity
CPT only copyright 2008 American Medical Association. All rights reserved.
7777
Let's ReviewWhat are the 7 components that define the levels of evaluation and management services?
HistoryExaminationMedical Decision MakingCounselingCoordination of CareNature of Presenting ProblemTime 7878
PROTECTING THE MEDICARE TRUST
FUND
CHAPTER 6
Chapter 6Pre-Assessment
8080
Medical Review Program
Analyze data Take action to prevent and/or address identified errors Publish local medical review policies
8181
National Coverage Determination
Identifies extent to which Medicare covers specific services, procedures, or technologies on national basis
8282
Local Coverage Determination
Developed to further define a National Coverage Determination or in absence of a specific National Coverage Determination
Made at Contractor’s discretion to provide guidance to public and medical community within specified geographic area
8383
Deterring Health Care Fraud and Program Abuse
Identify suspicious Medicare charges and activities
Investigate and punish those who commit Medicare fraud and abuse
Ensure money is returned to Medicare Trust Fund
8484
Federal Health Care Fraud Intentional use of false statements or fraudulent schemes to obtain payment for, or to cause another person or entity to obtain payment for, items or services payable under a Federal health care program
8585
Program Abuse Intentional or unintentional Directly or indirectly results in unnecessary or
increased costs to the Medicare Program
8686
Potential Legal Actions
Fine Prison sentence Temporary or permanent exclusion from
Medicare or other health care programs Lose license Civil Monetary Penalties
8787
Potential Legal Actions
Deny individual or entity’s application for Medicare provider billing privileges
Revoke provider’s billing privileges Suspend payment Exclusion from participation
8888
Report SuspectedFraud or Abuse
Office of Inspector General TIPS Hotline – (800) 447-8477E-mail – [email protected] Fax – (800) 223-8164
8989
Let's ReviewWhat are the 2 types of coverage
determinations that assist providers and suppliers in coding correctly and billing Medicare only for covered items and services?
What is program abuse?
9090
INQUIRIES, OVERPAYMENTS,
AND APPEALS
CHAPTER 7
Chapter 7Pre-Assessment
9292
Inquiries
Submit by telephone or in writing Interactive Voice Response Services
9393
Overpayments
Funds that a provider, supplier, or beneficiary received in excess of amounts due and payable
9494
5 Levels of Fee-For-Service Appeals First level – Redetermination by Medicare
Contractor Second level – Reconsideration by Qualified
Independent Contractor Third level – Hearing by Administrative Law
Judge Fourth level – Medicare Appeals Council
Review Fifth level – Judicial Review
9595
96
Reopening
Remedial action to change a final determination or decision that resulted in an overpayment or an underpayment
Allows correction of minor errors or omissions without initiating a formal appeal
9797
Let's ReviewUnder what circumstances are overpayments
often paid?What are the 5 levels in the appeals process?
9898
Post-Assessment Course Evaluation
Evaluation of course will be sent via emailCompletion of evaluation requiredThank you for your feedback
9999