Medical Ins. Billing Ch. 10

Medicare Participating Providers

- agree to accept assignment for all medicare claims & Medicare's fee as payment in full for services. - Responsible for informing patients when services will not, or a re not likely to be, paid by the program - Must comply with numerous billing rules such as global periods.

Paper claims slow cash flow because:

- paper claims must be held longer than HIPAA- compliant electronic claims - Paper claims cannot be paid before the 29th day after receipt of the claim, according to CMS guidelines

Medigap Insurance

- pays for services not covered by medicare - coverage varies, but all provide coverage for patient deductibles and coinsurance - Some also cover excluded services such as prescription drugs and limited preventative care.

ABN Section 1: Header

- shows the provider's name, address & phone number; may list more than 1 billing entity and contact person. - Patient Name - ID Number

ABN has 5 Sections

1. Header (Blanks A-D) 2. Body (Blanks D-F) 3. Options Box (Blank G) 4.Additional Informaiton (Blank H) 5. Signature Bos (Blanks I-J)

Three major tyes of Medicare Advantage Plans

1. Medicare coordinated care plans (CCPs) 2. Medicare private fee-for-service plans 3. Medical Savings Accounts (MSAs) - Medicare health Savings Account program

Medicare Part B (two types of plans)

1. Original Medicare Plan 2. Medicare Advantage Plans

Medicare Part D

Authorized under MMA, provides voluntary Medicare prescription drug plans that are open to people who are eligible for Medicare.

Urgently Needed Care

Beneficiary's unexpected illness or injury requiring immediate treatment.

Medicare Billing and Compliance

Complex - flow of claims - from provider - to the MAC - back to provider

ABN Section 2: Body

D. Descriptors (item, service, lab test, procedure, care etc.) E. Reason Medicare May Not pay (for this test for your condition, denied as too frequent a service, experimental or research use tests) F. Estimated cost

ABN Section 5: Signature Box

Done last, signifies beneficiary has reviewed and understands all information in the ABN

CCP Plans include the following:

HMOs= most restrictive plans / totally in-network POS = Point of Service (independent practices assoc) PPOs = in network, but may also go out of network SNPs = special Needs Plans RFBs = Religious Fraternal Benifits Plans

HPSA

Health professional Shortage Area - geographical areaoffering participation bonuses to physicians

Consultation codes; noncompliant billing

In 2010 Medicare stopped paying for all consultation codes from the CPT evaluation and management (E/M) codes.. except for G codes (telehealth consultations)

ABN Modifiers

Indicate whether an ABN is on file or was condsidered needed

Medicare Required Data Elements

Information in the Notes segment Diagnosis Codes Assumed Care Date / Relinquished Care Date

Medical Insurance biller must be familiar with rules & regulations for the practice's:

MAC CCi Edits & Global Surgical Packages Consultation Codes; Noncompliant billing Timely Filing Physician Quality Reporting Initiative (PQRI) MR - Medical Review Program RAC program - Recovery Audit Contractor Initiative Duplicate Claims Split billing

Who maintains lists of medigap companies?

MACs maintains this.

ABN's help beneficiary make an informed decision about out-of-pocket services and treatment

Mandatory ABNs Voluntary ABNs

CLCCP

Medicare Comprehensive Limiting Charge Compliance Program - created to prevent nonparticipating physicians from collecting the balance from medicare patients.

Medicare health insurace claim number (HCN)

Medicare beneficiary's identification number

Split Billing

Medicare considers a covered physician service provided at the same place on the same date as a preventive service to be separate and billable (with a -25 modifier) to show that a significatn, separately identifiable E/M service was provided.

Counseling Services

Medicare covers smoking and tobacco-use cessation counseling services

Medical Savings Accounts (MSAs)

Medicare health savings account program; high deductible fee-for-service plan with a tax-exempt trust to pay for qualified medical expenses.

Medicare card

Medicare insurance identification card

CCI Edits and Global Surgical packages

Medicare requires CPT/HCPCS coding. CCI is a list of CPT code combinations that, if used, would cause a claim to be rejected..... updated Quarterly

Timely Filing

Medicare requires claim to be filed no later than within one calendar year after the date of service.

Medical Review (MR) Program

Ongoing program in which MACs audit claims to check for inappropriate billing. They use the CERT program, Comprehensive Error Rate Testing - Probe review- checking 20-40 claims for errors - Prepayment review - form of probation after errors are found in probe review... teaches correct billing procedure - Postpayment review - another form of probation instead of prepayment review.... targets overbilling

Billing for Missed Appointments

PAR providers may bill Medicare beneficiaries for missed appointments as long as they also charge non-Medicare patients the same amount.

Different Fee structures for

PARs, nonPARs who accept assignment and nonPARs who do not accept assignment.

national coverage determination coverage (NCD)

Policy stating whether and under what circumstances a service is covered

Medigap Insurance

Private insurance that beneficiaries may purchase to fill in some of the gaps- unpaid amounts - in Medicare coverage.

Medicare as the Secondary Payer

Sometimes medicare pays benefits on a claim only after another primary insurance carrier has processed the claim. Medical Information specialist is responsible for knowing when medicare is the secondary payer.

Medicare Physician Fee Schedule (MPFS)

Source for regulations on global (surgical) packages .... similar to CCI for physician visits / procedures MPFS lists all the CPT/HCPCS codes and includes a column labeled GLOBAL PERIOD containing one of the indicators (000, 010, 090, MMM, XXX, YYY, ZZZ)

Online Eligibility Data

The healthcare Eligibility Transaction System (HETS) system allows release of elegibility date to Medicare providers

ABN Section 3: Options Box

This section is to be filled in by the patient, has 3 choices: 1. Receive items/services & requires a claim be submitted 2. receive items/services by paying out of pocket; no claim filed & Medicare not billed 3. Beneficiary opts out of receiving care May only choose 1 option

Preventive Services and Deductibles

Under medicare Part B, some preventive services are subject to a deductible, and some are not. The Medicare plan summary grid should note these requirements.

- GY Modifier

Used to speed Medicare denials so amount due can be collected from patient

Orignal Medicare Plan

a fee-for-service plan that provides maximum freedom of choice when selecting a provider or specialist

Physician Quality Reporting Initiative (PQRI)

a voluntary quality reporting program established by CMS in which physicians or other professionals collect and report their findings. Goal is to determine best practices, define measures, support involvement and improve systems

Nonparticipating providers under Medicare

accept 5% less for their services than PAR providers.

Recovery Audit Contractor (RAC) Initiative/program

aims to ensure that claims paid by the MACs are correct; Approx 6-10% of all claims are incorrect; RAC program is in all 50 states

PQRI Incentive

all or nothing lump-sum payment of additional 2 percent payment from CMS.

Original Medicare plan

allows the beneficiary to choose any licensed physician certified by medicare; - patients responsible for annual deductible - coinsurance

PQRI Claims

are reported on claims even though they have no direct monetary value. They are reported as either $0.00 or $0.01.

Initial preventive physical examination (IPPE)

benefit of a preventative visit for new beneficiaries

Spell of Illness / spell of illness benefit period

commences on the first day of the patient's stay in a hospital or skilled nursing facility and continues until sixty consecutive days have lapsed and the patient has received no skilled care.

medicare administrative contractor (MAC)

contractor who handles claims and related functions

supplemental Insurance

designed to provide additional coverage for an individual receiving benefits under medicare part B. (i.e. opt for this when retiring from a company) not regulated by CMS

(MSN) Medicare Summary Notice

document patients receive that details the services they were provided over a 30-day period; it details their services and charges.

The patient benefit with Medicare, the spell of illness,

does not end until 60 days after discharge from the hospital or skilled nursing facility. IF the patient is re-admitted within those 60 days, patient is considered to be within tose same benefit period on not subject to another deductible.

Advance Beneficiary Notice of NON coverage from CMS (ABN)

form used to inform patients that a service is not likely to be covered by Medicare and thus not reimbursed; Must be verbally communicated to beneficiary. patient must review and sign it. not required in Emergency situation.

fiscal intermediary

government contractor that processes claims

Medicare Advantage Plans/ (Medicare Part C)

group of managed care plans other thatn the Original medicare Plan. It offers 3 major types of plans

Quality Improvement Organization (QIO)

group of physicians paid by the government to review the Medicare program

Carrier

health plan

Limiting Charge

highest fee nonparticipating physicians may charge for a particular service ; they apply only to non participating providers submitting nonassigned claims; May not charge more than 115% OVER the nonPAR fee.

Medicare Coordinated Care Plan (CCP)

includes providers who are under contract to deliver the benefit package approved by CMS. Similar to an HMO network of providers.

Medicare Modernization Act MMA

law with a number of medicare changes, includeing a prescription drug benefit

Clinical Laboratory Improvement Amendments (CLIA)

laws establishing standards for laboratory testing

Waived Tests

low-risk laboratory tests physicians perform in their offices

medicare Part C

managed care health plans under the Medicare Advantage program.

Electronic Billing Compliance with HIPAA standards

mandates that electronic billing is mandatory except offices with fewer than 10 full-time employees.

medicare part D.

medicare prescription drug reimbursement plans

Common Working File (CWF)

medicare's master patient-procedure database

ZPICs Zone Program Integrity Contractors(ZPIC)

new fraud-detecting vendors who are hired by CMs for program integrity oversight for all Medicare-related claims in a jurisdiction.

Local coverage determination (LCD)

notices sent to physicians with informaion about the coding and medical necessity of a service.

Medicare Private Fee For Service plan; PFFS

patients receive services from Medicare-approved providers or facilities of their choosing.

Medicare Part A (Hospital Insurance (HI))

program that pays for hospitalization, care in a skilled nursing facility, home health care and hospice care

Medicare Part B (Supplementary Medical Insurance (SMI))

program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.

Nonparticipating providers are required to:

provide a surgical financial disclosure/advance written notification, when performing elective surgery that is $500+.

ABN Section 4: Additional Information

provider gives additional clarification

Notifier

provider who completes the header on an ABN

Voluntary ABN

replaces a formerly used form, the Notice of Exclusions from medicare Benefits (NEMB) for care that is never covered, i.e. personal comfort items; routine physicals & screenings; routine eye care; dental care; foot care

Medicare Advantantage organization (MAO)

responsible for providing all Medicare-covered services, except hospice care, in returen for a predetermined capitated payments. (may include vision, dental, hearing wellness)

Incident-to services

services of allied health professionals provided under the physician's direct supervision that may be billed under medicare

Roster Billing

simplified billing for vaccines

Screening Services

tests or procedures performed for a patient with no symptoms, abnormal findings or relevant history.

Duplicate Claims

those sent to one or more Medicare contractors from the same provider for the same beneficiary, same service and same date of service.

Medicare Part C

under part C private health insurance companies contract with CMS to offer Medicare beneficiaries medicare advantange plans that compete with the Original medicare plan.

MMA Medicare Modernization Act of 2003

under the Medicare Prescription Drug, Improvement and Modernization Act, in 2003 Advantage became the new name for Medicar + Choice plans, and certain rules were changed to give part C enrollees better beneifits and lower costs.

Medicare Part B (supplementary Medical Insurance)

voluntary program those desiring it must enroll, coverage is not automatic Beneficiaries pay a monthy premium based on SS benefit rates. Subject to annual deductible and coinsurance