Billing - Types of Insurance and Payers Flashcards
Who does Medicare cover
individuals who are elderly (age 65 or older) and individuals with permanent disabilities, end stage renal disease (ESRD), or Lou Gehrig’s disease.
Describe Medicare Part A
Medicare Part A is hospital insurance and covers:
* Medically necessary inpatient hospitalization
* Care in a skilled nursing facility (SNF) following a three-day hospital stay
* Home health care
* Hospice
Do beneficiaries pay a premium for Medicare Part A coverage?
Most beneficiaries do not pay a premium. Beneficiaries who have worked enough quarters per SSA requirements will qualify for coverage without a premium. Beneficiaries who have not worked enough quarters may still qualify for coverage but would be responsible for their individual premium.
Do beneficiaries pay a deductible for Medicare Part A coverage?
Patients pay a deductible for Part A coverage once per spell of an illness (also known as the benefit period), which begins when a beneficiary enters the hospital and ends 60 days after discharge from the hospital or from a SNF.
What does the acronym “LTR” stand for?
Life Time Reserve
Describe Life Time Reserve for Part A coverage
Part A benefits include a “lifetime reserve” (LTR) of 60 days of inpatient hospital services that a beneficiary can opt to use after having used 90 days of inpatient hospital services in a benefit period.
This 60-day reserve comes with a high coinsurance (50% of the Medicare Part A deductible per day) and can be used only once in the beneficiary’s lifetime (but can be split among multiple hospital stays).
If a patient chooses not to use lifetime reserve days after a 90-day stay, any covered Part B services (described below) would be billed.
Describe Medicare Part B
Medicare Part B, medical insurance, helps pay for doctor services, outpatient hospital care, and some other medical services that Part A does not cover (such as the services of physical and occupational therapists, and some home health care).
Part B helps pay for these covered services and supplies when they are medically necessary.
Medicare Part B also covers certain screening and preventive services. All services are based on the provider accepting assignment and a written order.
Part B also helps pay for:
* Ambulance services (when other transportation would endanger your health)
* Artificial limbs and eyes
* Arm, leg, back, and neck braces
* Chiropractic services (limited)
* Emergency care
* Eyeglasses (one pair after cataract surgery with an intraocular lens)
* Immunosuppressive drug therapy (limited), extended coverage available for transplant
* Kidney dialysis and kidney transplants
* Therapeutic shoes for people with diabetes (in some cases)
* Medical supplies, such as ostomy bags, surgical dressings, splints, casts, and some diabetic supplies
* Outpatient prescription drugs (very limited, for example, some oral cancer drugs)
* Prosthetic devices, including breast prosthesis after mastectomy
* Services of practitioners, such as clinics, psychologists, social workers, and nurse practitioners
* Telemedicine services in some rural areas
* Transplants (heart, lung, kidney, pancreas, and liver; under certain conditions)
* X-rays, MRIs, CT scans, EKGs, and some other diagnostic tests
Describe Medicare Part C
Medicare Part C, also known as Medicare Advantage or a Replacement Plan, is a replacement for traditional Medicare. This is managed care coverage provided by private insurance companies approved by Medicare. The private insurance companies are paid a fixed amount each month. These plans must follow the minimal rules set by Medicare. Depending on if the provider is contracted with the payer, the payment received may be the same, more, or less than traditional Medicare.
What are the 5 types of Medicare Advantage Plans?
- Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPOs)
- Private Fee-for-Service Plans
- Special Needs Plans
- Medical Savings Accounts (MSAs)
Describe Health Maintenance Organizations (HMOs)
Type of Medicare Advantage Plan in which members must generally get healthcare from providers in the plan’s network.
Desribe Preferred Provider Organizations (PPOs)
Type of Medicare Advantage Plan which are similar to HMOs, but members can see any doctor or provider that accepts Medicare and they don’t need a referral to see a specialist.
Describe Private Fee-for-Service Plans
Type of Medicare Advantage Plan which allows members to go to any provider that accepts the plan’s terms. The private company decides how much it will pay and how much members pay for services.
Describe Special Needs Plans
Type of Medicare Advantage Plan which limits all or most of their membership to people in some Long Term Care facilities (such as nursing homes), and who are eligible for Medicare and Medicaid. These plans are available in limited areas only
Describe Medical Savings Accounts (MSAs)
Type of Medicare Advantage Plan which has two parts:
* one part is a Medicare Advantage high-deductible plan
* the other part is a Medical Savings Account into which Medicare deposits money that people can use to pay healthcare costs
What 2 factors determine whether the Medicare Advantage organization is liable for the payment?
- Whether the provider is included in an inpatient hospital or home health prospective payment system (PPS)
- The date of enrollment
If the patient changes Medicare Advantage status during the hospital inpatient stay, the patient’s status at admission or start of care determines liability. If the hospital inpatient was not a Medicare Advantage enrollee upon admission but enrolls before the discharge, the Medicare Advantage organization is not responsible for payment.
If the provider is not a PPS provider, the Medicare Advantage organization is responsible for payment for services on and after the day of enrollment up through the day that disenrollment is effective.
Describe Medicare Part D
Medicare Part D is the Medicare Prescription Drug Plan and covers medication subject to an annual deductible. The Medicare Drug Plan selected has a list of covered drugs, which is known as the “formulary.” Drugs are placed into tiers and each tier can have a different cost.
Describe the Medicare Administrative Contractor (MAC)
Medicare Administrative Contractors (MACs) are the private firms that process Medicare claims. MACs were formerly known as fiscal intermediaries or carriers. MACs also serve as the primary operational contact for providers. They enroll providers in the Medicare program, provide education on Medicare billing requirements, and answer both provider and patient inquiries.
How many Medicare Adsministrative Contractors (MACs) are there?
12 Part A / Part B MACs and 4 DME MAC jurisdictions
Describe the Medicare Participating Physician Program
Under the Medicare Participating Physician Program, doctors sign a “participation agreement” binding them to accept assignment for all services provided to Medicare patients for the following year.
The assignment of benefits is normally acquired at registration or admission. It is not essential to obtain assignment prior to rendering treatment, but it is imperative that it be obtained prior to discharge.
By participating/accepting assignment under the Medicare Participating Physician Program, providers agree to what 3 things?
- Be paid by Medicare
- Get only the amount Medicare approves for their services; they cannot use an ABN or similar contract to get the patient to pay more
- Charge beneficiaries only the cost of noncovered services and the Medicare deductible/coinsurance amount
Under the Medicare Participating Physician Program, if providers do not participate/do not accept assignment, what thing can/must they do (4)?
- Can charge more than the Medicare approved amount (a maximum of 115% of the approved amount)
- Can ask the beneficiary to pay the entire charge at the time of service
- Must determine whether the services they are furnishing are covered under Medicare
- Must still submit a claim to Medicare, with all supporting information, when they provide a beneficiary with Medicare covered services
What are the advantages of participating in the Medicare Participating Physician Program (6)?
- Higher fee schedule payments
- Fewer collection efforts (Medicare pays 80% directly to the provider of service.)
- Publicity
- Government imprimatur (meaning “sanction” or “approval”; ability to display Medicare emblems and literature)
- Accurate calculation of coinsurance, allowing for front-end collection practices
- Lower fee maintenance
Why is it helpful to obtain a copy of the patient’s Medicare card when providing services.
When submitting a claim to Medicare, the name on the claim must match the name on the card exactly.
How can staff differentiate between Part C and Traditional Medicare cards?
- Most often, the back of the Part C card will indicate “Do not bill Medicare.”
- The address to mail or electronically send claims will be different from the Medicare Administrative Contractor (MAC).
