Mod 7 Medicare
Exceptions
Provisions have been for cases atypically expensive (based on the diagnosis) because of complications or an abnormally long confinement. Known as outliers. These cases will be reimbursed on an itemized or cost percentage basis rather than DRG
Diagnosis-Related Group Billing
In early 1980s, Medicare instituted Diagnosis related group (DRG) payments for inpatient hospital claims.
The actual processing of the claims is administered by
by many different insurance companies, usually one or two within each state
Medicare Part B
covers physician services, outpatient hospital services, home health care, outpatient speech and physical therapy, and durable medical equipment
Medicare payments are based on
"reasonable charges" which are the amt approved by the Medicare carrier based on what is considered reasonable for the geographic area in which the doctor practices
Medicare eligibility is based on
1. Age 2. Disability 3. ESRD
Medicare Part A, the hospital portion, is automatic on enrollment for the individuals 1
All people age 65 and over, if entitled to (a) monthly Social Security benefits or(b) pensions under the Railroad Retirement Act
Medicare Part A, the hospital portion, is automatic on enrollment for the individuals 2
All people who reached the age of 65 before 1968, whether or not under the Social Security or Railroad Retirement Programs
Medicare coverage for totally disabled persons
Begins on the 25th month from the date approved for social security disability or Railroad Retirement bebefits
A participating provider must agree to accept assignment on all Medicare claims
By doing this, the payment goes directly to the provider for all claims, rather than to the member
Exclusions
Excluded from DRG are long-term case, children's care, and psychiatric and rehabilitative hospital
Medicare
Federal health Insurance Benefit Plan for the Aged and Disabled
Medicare Part C
Medicare advantage portion and includes coverage in an HMO, PPO and so on.
End-Stage renal diseases (ESRD) coverage
Medicare is the secondary payer during this 30-month period but will revert to the primary status beginning with the 31st month. As a general rule, all services under a dialysis program are medicare assigned
When a physician agrees to accept Medicare assignment for a bill
Medicare pays the physician directly for that bill
Most Common methods in use for coordination of benefits with Medicare
Nonduplication of Medicare Maintenance of benefits coordination of benefits medicare supplemental coverage
Medicare Part A, the hospital portion, is automatic on enrollment for the individuals 4
Some spouses may receive Medicare benefits derived strictly from their eligible spouse's work credit. Using the eligible spouse's social security number withe appropriate letter behind is designates benefits are based on the eligible spouse
TEFRA/DEFRA
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) and amendments to it - has redirected the financial responsibility for medical coverage of active employees age 65 years and older and their spouses aged 65 years and older.
End-Stage renal diseases (ESRD) coverage
The employer's group health plan is the primary payer for the first 30 months after a patient (under age 65) with ESRD become eligible for Medicare
Medicare allowance
The total fee that a physician may receive from Medicare and from beneficiaries for an assigned bill is limited by what Medicare deems an appropriate fee for the particular service or procedure
Coordination of Benefits with Medicare
There are a variety of ways in which group health plans coordinate their payments with Medicare when Medicare is primary and the group plan is secondary
Medicare Part A, the hospital portion, is automatic on enrollment for the individuals 3
Workers who reach 65 in 1975 or after need 20 quarters of Social Security work credits if female, or 24 quarters if male, to be fully insured
Under DRG
a flat rate payment is made based on patient's diagnosis rather than the hospital's itemized billing
MSN - Medicare Summary Notice
an explanation of benefits sent to the Medicare beneficiary also called EOMB - Explanation of Medicare Benefit
Medicare Supplement
are separate plans written exclusively for Medicare participants. Covers items Medicare does not cover
Nonduplication of Medicare
calculation of benefits under the nonduplication approach is the same as with COB except that allowable
after determined that the group plan is subject to TEFRA/DEFRA, it becomes necessary to
determine the individual's eligibility for Medicare
Initially, TEFRA/DEFRA regulations
did not apply to spouses over age 65 of active employees who were under 65 yrs of age
Deficit Reduction Act of 1984 (DEFRA)
effective 1/1/1985, amended TEFRA so that now spouses age 65 yrs and older of active employees who are under age 65 can elect their primary coverage as either medicare or the private group plan
Employers with fewer than 20 employees
exempt from TEFRA/DEFRA regulations, and Medicare is the primary carrier for their active employees and spouses age 65 yrs or older
Part A benefits
if a member remains in the hospital for an extended period of time, additional copayments are required. Medicare deducts the copay amount from the billed amt and then pays the amt in excess of the copay
Medicare Part A
is considered the basic plan or hospital insurance. This part covers facility charges for acute inpatient hospital care, skilled nursing, home health care, and hospice care
Medicare program
is for people 65 years of age or older and certain persons who are totally disabled
End-Stage renal diseases (ESRD)
is the condition in which a person's kidneys fail to function
Medicare Part D
is the prescription drug component
When TEFRA/DEFRA was introduced
it was determined that Medicare would be the primary payer for persons who have reached their 65th birthday, regardless of employment status
Providers of services and medical equipment suppliers under Medicare
must meet all icensing requirements of the state in which they are located. To be a participating provider under the Medicare program
An individual is eligible for Medicare coverage
on the first day of the month in which he or she reaches age 65
balance billing
participating physicians agree not to practice or charging patients for more than the Medicare allowance
Maintenance of Benefits
refers to a provision in many group health plans that allows the person who has Medicare to "maintain" the same group benefits as members who do not have Medicare
Medicare Part B
supplementary medical insurance, which covers physician and outpatient hospital services. It is considered a supplemental plan because each participant must pay a stipulated amt each month for the benefits. Private insurance companies, called carriers, process Part B claims The rules, limits, and maximums under this coverage are subject to change annually
Social Security Administration (SSA) offices
take applications for Medicare, determine eligibility, and provide general information about the program
The physician may bill the patient only for any deductibles or coinsurance
that medicare has deducted from the assigned bill
Medicare Part B benefits
the 2006 deductible is $124 per calendar year. After the deductible has been satisfied, generally 80% of the approved charge will be paid Beginning Jan 1, 2006, the Mediare Part B deductible will be indexed to the increase in the average cost of part B services for Medicare beneficiaries
The charge approved by the carrier is the lowest of either of the following:
the charge billed by the provider, or the prevailing charge (based on all the customary charges in the locality for each type of service) as determined by Medicare
The employers affected by these Acts are
those who regularly employ 20 or more workers for each working day in at least 20 wks of current or preceding calendar year
participating physician
to encourage physicians to accept assignment, the Medicare allowance is higher for physicians who agree to accept assignment for all bills for medicare-eligible persons.
