Discuss the Different Government-Sponsored Healthcare Programs Flashcards
What does Medicare use?
UPICs (Unified Program Integrity Contractors).
What are UPICs (Unified Program Integrity Contractors)?
Contracts that use data analysis to identify billing trends that are outside the norm. (such as higher level of provider bills per speciality or services added that don’t go together.
What is a Recovery Audit Contractor?
Contractors that audit claims when CMS suspects fraud, waste, abuse, or error in claims being billed. (Especially through Medicare and Medicaid).
What does the Office of the Inspector General (the OIG) do?
Investigates instances of fraud and abuse and pursues legal action against providers if applicable.
Often take results from UPIC and RAC organizations and study their findings.
What are some indicators of fraud and abuse that the OIG, UPIC, and RAC look for?
-Overuse of modifiers that override NCCI edits
-Billing services more frequently than other providers of the same specialty.
-Billing E/M Codes with every surgical procedure may raise red flags with an audit.
YOULL GET RAC AUDITS REGARDLESS OF ILL USE
What is Medicare Part A?
Hospital insurance Coverage
-Financed almost entirely by a universal tax on employee pay.
-No premiums required if medicare taxes were deducted from one’s income.
-Covers specific healthcare services related to hospitals:
- Inpatient Hospital, Long-term Care,
Skilled Nursing Facilities, Home Health
Care, and Hospice Care.
What is Medicare Part B?
Supplemental medical insurance coverage.
-Requires a premium
-Voluntary program
-Not automatically signed up for this.
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-Helps pay for: Physician services, outpatient hospital services, outpatient physical therapy, and speech pathology (that aren’t covered in Part A).
What is Medicare Part C?
Medicare advantage
-Provides alternative insurance providers rather than the government for services not covered in Part A or B.
-Offers: New beneficiary and plan enrollment systems, payment systems, appeals procedures, quality assurance, and national medical-education campaign.
What is Medicare Part D?
Prescription drug plan.
-add on coverage for prescription drugs provided through medicare-approved insurance companies.
-Must have plan A or B depending on drug coverage chosen.
What makes you eligible for medicare?
65 or older, US Citizen or Permanent resident, you or spouse must have 10 years of medicare-covered employment,
If under 65, you can qualify if you have disability benefits under Social Security or railroad retirement. Or specific kidney-related health issues.
What did the Balanced Budget Act (BBA) provide?
Established Part C (in addition to Parts A and B of Medicare)
New Payment Systems for medicare services to improve accuracy and reduce healthcare spending
Expanded preventative care benefits
Established State Children’s Health Insurance Program (SCHIP)
New eligibility options for Medicaid
Expanded assistance for low-income Medicare beneficiaries
New Quality standards for Medicaid managed-care prgorams.
What is medigap insurance?
Health insurance plan that fills the ‘gaps’ in Medicare plan coverage.
What is a managed care plan?
Plan that involves financing, managing, and delivery of healthcare services.
Usually involves a group of providers who share the financial risk of the plan or who have an incentive to deliver cost-effective, quality healthcare services.
What is a fee-for-service plan?
Physician and other providers receive payment based on their billed charge for each service provided.
What are the two eligibility groups for Medicaid?
Categorically needy and medically needy.
