Mod 7 Medicare

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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.


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