copyright © 2008 delmar learning. all rights reserved. chapter 14 medicare
TRANSCRIPT
Copyright © 2008 Delmar Learning. All rights reserved.
Chapter 14
Medicare
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2
Introduction
• Medicare is the largest medical program in the United States
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3
Medicare Is a Two-Part Program
• Medicare Part A: – Reimburses institutional providers for
inpatient, hospice, and some home health services
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4
Medicare Is a Two-Part Program
• Medicare Part B: – Reimburses institutional providers for
outpatient services and physicians for inpatient and office services
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5
Medicare Program Includes
• Medicare Hospital Insurance: – Inpatient hospital critical care access– Skilled nursing facility– Hospice care– Some home health care
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6
Medicare Program Includes
• Medicare Medical Insurance: – Pays for doctors’ services, outpatient hospital
care, durable medical equipment, and some medical services that are not covered by Part A
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7
Medicare Program Includes
• Medicare Advantage: – Formerly called Medicare+Choice– Includes managed care and private fee-for-
service plans that provided contracted care to Medicare patients
– Medicare Advantage is an alternative to the original Medicare plan reimbursed under Medicare Part A
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8
Medicare Program Includes
• Medicare Prescription Drug: – Adds prescription drug coverage to the
original Medicare Plan, some Medicare Cost, some Medicare Private Fee-for-Service Plans, and Medicare Medical Savings Account Plans.
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9
Medicare Eligibility
• Individuals or their spouse to have worked at least 10 years in Medicare-covered employment.
• Individuals to be a minimum age of 65 years old.
• Individuals to be a citizen or permanent resident of the United States.
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10
Medicare Part A 65 Years or Older
• Receiving retirement from SS or RRB
• Not receiving benefits but are eligible
• Had Medicare-covered government employment
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11
Medicare Part A Under Age 65
• Have received Social Security or RRB disability for 24 months
• Have end-stage renal disease
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12
Hospitalizations
• Medicare pays only a portion of a patient’s acute care and CAH inpatient hospital expenses– Patient’s out-of-pocket expenses are
calculated on a benefit-period basis
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13
Medicare Part B
• Medicare Part B – Helps pay for physician services– Outpatient hospital care– Some physical and occupational therapy– Some home care
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14
Medicare Part C
• Is managed by private companies but are health plans that are approved by Medicare
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15
Medicare Advantage Plans
• Require referrals to see specialists
• Offer lower premiums or copayments and deductibles than the original Medicare Plan
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Medicare Advantage Plans
• Have networks– Patients may have to see doctors who belong
to the plan or go to certain hospitals to get covered services
• Offer extra benefits, such as prescription drug coverage
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Medicare Advantage Plans
• Coordinate patient care, using networks and referrals– Can help with overall care management and
result in cost savings
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18
Medicare Advantage Plans
• Medicare patients have the option of enrolling in one of these plans:– Health Maintenance Organization (HMO)– Medicare Medical Savings Account Plan– Medicare Special Needs Plan
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19
Medicare Advantage Plans
• Preferred Provider Organization (PPO)
• Private fee-for-service plan (PFFS)
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20
Medicare Special Needs Plans
• Covers Medicare A and B– For individuals who have chronic illnesses– Managing multiple diseases– Who can benefit the most from special
care
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May Limit Certain Individuals
• Those who are eligible for both Medicare and Medicaid
• Those who have certain chronic or disabling conditions
• Those who reside in certain institutions
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22
Medicare D
• Offers prescription drug coverage to all Medicare patients– May help lower the drug costs and help
protect against higher costs in the future
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23
MEDIGAP
• Pays for services that Medicare does not pay for
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24
Other Medicare Health Plans
• Medicare Cost Plans
• Demonstration/Pilot Program
• Programs of all-inclusive care for the elderly (PACE)
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25
Medicare Cost Plan
• Is a type of HMO– Works much in the same way that
Medicare Advantage Plan does
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Demonstration/Pilot Program
• A special Project that tests improvements in Medicare coverage, payment, and quality of care.
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27
PACE
• Combine medical, social, and long-term care services for frail people who live and receive health care in the community
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Eligibility for PACE
• 55 years old, or older
• Resident of the service area covered by the PACE program
• Able to live safely in the community
• Certified as eligible for nursing home care by the appropriate state agency
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29
Participating Providers
• Medicare has an agreement with participating providers to accept assignments on all Medicare claims
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The Agreements Include
• Direct payment of all claims
• Five percent higher fee schedule than for nonparticipating providers
• Bonuses provided to Medicare administrative contractors for recruitment and enrollment of PARs
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The Agreements Include
• Publication of an annual, regional PAR directory made available to all Medicare patients
• Faster processing of assigned claims
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The Agreements Include
• A special message printed on all unassigned Medicare Summary Notice forms mailed to patients– Reminds them of the reduction in out-of-
pocket expenses if they use PARs and stating how much they would save with PARs
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33
The Agreements Include
• Hospital referrals for outpatient care that provide the patient with the name and full address of at least one PAR provider each time the hospital provides a referral for care.
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34
Nonparticipating Providers
• Nonparticipating providers may chose claim-by-claim assignments, but there are some restrictions
• NonPARs must file all Medicare claims
• Balance billing of the patient by a non-PAR is forbidden
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35
Nonparticipating Providers
• Fees are restricted to not more then the “limiting charge” on nonassigned claims
• Collections are restricted to only the deductible and coinsurance due at the time of service on an assigned claim
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36
Nonparticipating Providers
• Patients must sign a surgical disclosure notice for all nonassigned surgical fees over $500
• NonPARs must accept assignment on clinical laboratory charges
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37
Privacy Act
• Privacy Act of 1974 – Does not allow the Medicare administrative
contractor to reveal the status of any unassigned claim other than the date the claim was received by the MAC
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38
Privacy Act
• Date the claim was paid, denied, or suspended
• General reason the claim was suspended
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39
Surgical Disclosure Notice
• Elective surgery is defined as a surgery that:– Can be scheduled in advance– Is not an emergency– If delayed, would not result in death or
permanent impairment of health
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40
Private Contracting
• “Under the Balanced Budget Act of 1997, physicians were provided the option of withdrawing from Medicare and entering into private contracts with their Medicare patients.”
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Under a Private Contract
• No medicare payment will be made for services or procedures provided to a patient.
• Other insurance plans may not pay for services or procedures rendered.
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Under a Private Contract
• Medicare managed care plans will not pay for services rendered under a private contract.
• No claim is to be submitted to Medicare– Medicare will not pay if a claim is submitted
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43
Under a Private Contract
• Supplemental insurance will not pay for services or procedures rendered
• Patient is required to pay whatever the physician/practitioner charges– There is no limit on what the physician can
charge for Medicare approved services
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44
Medicare Summary Notice
• Is a monthly statement that is easy to read that clearly lists health insurance claims information
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Claims Instructions
• The law says that all Medicare claims must be filed using optical scanning guidelines.
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46
Medicare and Medigap Claims
• Changes must be made to the Medicare main claim when:– Health care provider is a Medicare PAR– Patient has a Medigap policy in addition to
Medicare– Patient has signed an Authorization for
Release of Medigap Benefits
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47
Medicare-Medicaid Crossover
• A Medicare-Medicaid crossover plan provides both Medicare and Medicaid coverage to certain eligible beneficiaries
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48
Medicare asSecondary Payer Claims
• Medicare Secondary Payer (MSP) program – Organizes benefits between Medicare and
additional payers to determine if an additional insurance plan is primary.
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Medicare as Secondary Payer Claims
• Contractors uses some of the following to identify insurance primary to Medicare– Initial Enrollment Questionnaire (IEQ)– IRS/SSA/CMS/ Data Match– MSP claims Investigation– Voluntary MSP Data Match Agreements
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50
Roster Billing
• Process to enable Medicare beneficiaries to partake in mass pneumococcal pneumonia virus and influenza virus vaccination programs – Offered by community health clinics and other
entities that bill Medicare