billing chapter 8

verifying Medicaid eligibility

1. Patient;s ID card 2. automated voice response(AVR) system 3. electronic data interchange(EDI) 4. point-of-sale device 5. computer software program

accepting Medicaid Patients

1. physicians have the choice of whether or not to accept Medicaid patients 2. In most states, physicians can limit the number of Medicaid patients they accept.

remittance advice (RA)

A document is generated explaining how the claim was adjudicated, or how the payment was determined, in Medicaid, calls it the remittance advice.

budget period

Almost any medical bills that the applicant or the applicant's family still owes or that were paid in the months for which Medicaid is sought.

Countable income

Amount of income left over after eliminating all items that are not considered income and applying all appropriate exclusions to the items that are considered income

Fraud

An intentional misrepresentation or deception that could result in an unauthorized benefit to an individual or indivuduals and usually comes in the form of a false statement requesting payment under the Medicaid program.

medically necessary

As a general rule, Medicaid pays only for services that are determined to be medically necessary.

accepting assingment

CMS-1500 block 27, if it is not checked "yes", the claim may be denied. Providers participating in Medicaid must accept the Medicaid reimbursement as payment in full.

medicaid claims

CMS-1500claim is accepted .some states have their own form

mandated services

Certain basic services that must be offered to the categorically needy population in any state Medicaid program.

capitation

Common method of reimbursement used primarily by health maintenance organizations in which the provider or medical facility is paid a fixed, per capita amount for each individual enrolled in the plan, regardless of how many or few services the patient uses.

spend down

Depleting private or family finances to the point where the individual or family becomes eligible for Medicaid assistance.

adjudicated

How a decision was mede regarding the payment of an insurance claim.

Supplemental Security Income (SSI) program

In 1972, federal law established the Supplemental Security Incom (SSI) program, which provides federally funded cash assistance to qualifying elderly and disabled poor. 1. Social Security Administration determines eligibility criteria and sets the cash benefit amounts fro SSI. 2. the amount of the SSI payment is the difference between the individual's countable income and the Federal Benefit Rate.

federal poverty level (FPL)

Income standards that are updated annually and that serve as one of the eligibility factors for various state and federal assistance programs.

cost sharing (share of cost)

Medicaid beneficiaries pay a portion of their health costs, such as deductibles, coinsurance, or copayment amount.

Medicare hospital insurance (Medicare HI)

Medicare Part A

Qualified Medicare Beneficiaries (QMBs)

Medicare beneficiarieswho qualify for certain additional benefits only if they have incomes below the federal poverty level and resources at or below twice the standard allowed under the Supplemental Security Income program

medically needy programs

More than 40 stats plus the District of Columbia operate medically needy programs,which allow them to provide Medicaid to certain goups of individuals who are not otherwise eligible for Medicaid. 1. states that offer a medically needy program must cover pregnant women and children younger than 18 years. 2. it may also expand coerage to people who spend down rtheir income by accumulatin medical expenses so that their income falls below a state-established medically needy income limit.

Balance billing

Practice of billing patients for any balannce left after deductibles, coinsurance, an insurance payments have been made. This is not allowed.

Supplemental medical insurance (SMI)

See Medicare supplement plans and Medigap insurance

optional services

Services for which federal funding is available. States can provide as many or as few as they choose to their categorically needy population. Some of these services include dental services, clinic services, optometrist services and eyeglasses, and prescribed drugs

Time Limit for filing Medicaid Claims

The time limit for filling Medicaid claims varies from state to state, anywhere from 2 months to 1 year.

Program of All-Inclusive Care for the Elderly (PACE)

This program provides comprehensive alternative care for noninstitutionalized elderly people who otherwise would be in a nursing home.

Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT)

This program was developed to fit the standards of pediatric care and to meet the special physical, emotional, and evelopmental needs of low-income children.

Abuse

Typically involves payment for items or services in the outcome of poor and inefficient methods results in unnecessary costs to the Medicaid program.

categorically needy

Typically used to describe low-income families with children; individuals receiving Supplemental Security Income; Pregnant women, infants, and children with incomes less than a specified percent of the federal poverty level; and Qualified Medicare Beneficiaries.

dual coverage(Medi-Medi)

When aged or diabled , or both, individuals who are very poor are covered under the Medicaid and Medicare programs, these indivuduals may receive Medicare services for which they are entitled and other services available under that states Medicaid program.

Medicare-Medicaid crossover claims

When the patient has dual eligibility for Medicaid and Medicare(Medi-Medi), Medicare is primary. In this case, the claim is submitted first to Medicare, which pays its share and then "crosses it over" to Medicaid.

Medicaid

a combination federal and state medical assistance program designed to provide comprehensive and quality medical care for low-income families, with special emphasis on children, pregnant women, the elderly, the diabled, and parents with dependent children who have no other way to pay for healthcare. 1. a major social welfare program 2.administered by the Centers fro Medicare and Medicaid Servies (CMS) 3.largest source of funding for safety-net-providers that serve the poor and uninsured. 4.payments are made directly to the healthcare provider.

Medicaid contractor

a commercial insurer contracted by the HHS for the purpose of processing and administering claims.

The Community First Choice (CFC) Option

a relatively new state option that gives individuals with disabilities who are eligible for nursing homes and other institutional settings options to receive community-based services.

payer of last resort

all other available third-party resources must meet their legal obligations to pay claims before the Medicaid program pays for the care of an individual eligible for Medicaid.

Medicaid Home and Community-Based Services (HCBS)Waivers

allow states the flexibility to develop and implement creative altenatives to placing Medicaid-eligible individuals in hospitals, nursing homes, or intermediate care facilities for persons with mental retardation.

State children's health Insurance Program (SCHIP)

as part of the Balanced Budget Act of 1997, later known more simply as the Children's Health Insurance Program (CHIP)

Specified Low-Income Medicare Beneficiaries (SLMBs)

beneficiaries with resources similar to Qualified Medicare Beneficiaries but with slightly higher incomes.

safety-net providers

community health centers and public hospitals

disproportionate share hospitals

facilities that receive additional payments to ensure that communities have access to certain high-cost services, such as trauma and emergency care and burn services.

in-kind income

is not cash, it is food, clothing, shelter, or something one can use to obtain food(such as food stamps), clothing, or shelter.

cost avoid

is the process by which the healthcare provider bills and collects from liable third parties before sending the claim to Medicaid. States generally are required to cost-avoid claims unless they have a waiver approved by CMS that allows them to use the pay-and-chase method.

Maternal and Child Health Services

operated as a federal-state partnership for more than 65 years,to improve the health of all mothers and children consistent with the health status goals and national health objectives established by the Secretry of the U.S. Department of Health and Human Services

dual eligibles

patients have both Medicare and Medicaid coverage

medicaid integrity contractors (MICs)

private companies that conduct audit-related activities under contract to the Medicaid Integrity Group (MIG).

third-party liability

refers to the legal obligation of third parties to pay all or part of the expenditures for medical assistance furnished under a state plan.

Copayments

the DRA Act impose copayments and premiums to certain categories of Medicaid recipients.

Temporary Assistance for needy Families (TANF)

the Medicaid program, referred to in the past as Aid to Families with Dependent Children (AFDC), is now called TANF(renamed)

reciprocity

the occurrence of a situation in which individuals or entities offer certain rights to each other in return for the rights being given to them.

Medicaid "simple" claim

the patient hads Medicaid coverage only and no secondary insurance.

Medicaid secondary claim

when the beneficiary has two types of healthcare coverage, Medicare and medical insurance coverage (such as commercial or group policies) or dual coverage with traditional (original) Medicare enrollment.

pay and chase claims

when the state Medicaid agency goes ahead and pays the medical bills and then attempts to recover these paid funds from liable third parties.

Qaulified Disabled and Working Individuals(QDWIs)

who lose their Medicare benefits because they returned to work. are allowed to purchase Medicare hospital insurance (Medicare HI)