Federal Insurances

Question 1

What are three federal insurances?

Answer 1

Medicare, Medicaid, Tricare

Question 2

What is DEERS?

Answer 2

This is the Defense Enrollment Eligibility Reporting System. This is used by claims processing to ensure eligibility.

Question 3

What is MLN?

Answer 3

Medicare Learning Network. This is the official CMS national provider education product designed to promote the national consistency of Medicare provider information.

Question 4

What is MAC?

Answer 4

A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare claims.

Question 5

What is a RAC?

Answer 5

Recovery Auditor Contractor. They identify and recover improper Medicare payments paid to healthcare providers under Medicare plans. They run the audits.

Question 6

What is covered in Medicare Part A?

Answer 6

Part A reimburses services done at inpatient hospitals, skilled nursing facilities, hospices, and some home health services.

Question 7

What is covered in Medicare Part B?

Answer 7

Part B is a fee-for-service plan that reimburses professional services, outpatient hospital care, and durable medical equipment(DME).

Question 8

What is Medicare Part C?

Answer 8

Part C is when a patient chooses a Managed Care Plan or chooses to receive their Medicare benefits through private insurance(MA-Medicare Advantage Plan or Medicare Replacement Plan). These plans include parts A, B, and additional services like vision and dental.

Question 9

What is covered in Medicare Part D?

Answer 9

Part D offers plans that cover prescription medications at a discounted rate to Medicare-eligible beneficiaries. D for Drug!

Question 10

What is Medicares coverage?

Answer 10

After the deductible has been met, Medicare will pay 80% of the Allowable amount, while the patient pays the remaining 20%.

Question 11

When was Medicare established?

Answer 11

1965

Question 12

What is Medigap?

Answer 12

A Medigap is a supplemental policy offered by private insurances that cover the remaining balance after Medicare has paid. Medigap coverage varies by the plan’s letter.

Question 13

Which federal insurances have a Timely Filing limit of one year?

Answer 13

Medicare and Tricare. Medicaid varies by state.

Question 14

What do Medicare Fee-For-Service claims rely on?

Answer 14

Instead of requiring preauthorizations, Medicare relies on Medical Necessity.

Question 15

What happens if Medicare deems a claim not Medically Necessary?

Answer 15

The claim will be denied and you cannot bill the patient. You can appeal the decision with additional documents.

Question 16

What is the Qualified Medicare Beneficiary Program(QMBP)?

Answer 16

This assists with Part A and B premiums, Copayments, Deductibles, and Coinsurance Amounts.

Question 17

What is Specified Low-Income Medicare Beneficiary (SLMB)?

Answer 17

This requires the state to pay for the Medicare Part B Premiums.

Question 18

What is Dual Eligibility?

Answer 18

This is a program to assist Medicare qualified patient’s who are low-income and need help covering Medicare premiums, copayments, coinsurances, and deductibles.

Question 19

What are the HCPCS codes Medicare requires?

Answer 19

G codes

Question 20

What is a Crossover Claim?

Answer 20

When Medicare is the Primary Payer, it will adjudicate the claim and forward the remaining balance to the Secondary Payer.

Question 21

How is Medicaid managed?

Answer 21

Each state manages its own Medicaid programs. They are jointly funded by the federal and state.

Question 22

How do you qualify for Medicaid?

Answer 22

The patient must be low-income, pregnant, disabled, or needs long-term care.

Question 23

How do you qualify for Medicare?

Answer 23

The patient must be 65 years or older, disabled, or has end-stage renal disease(ESRD)

Question 24

How do you qualify for Tricare?

Answer 24

Must be enrolled or retired from the military or be a family member.

Question 25

What is Medicaid’s Out-Of-Pocket expenses?

Answer 25

Medicaid patients are covered 100% no OOP expenses.

Question 26

If a patient has Medicare as the primary payer and Medicaid or Tricare as secondary, will the patient have a balance?

Answer 26

No, Medicaid and Tricare pick-up 100% after Medicare.

Question 27

What is ZPIC?

Answer 27

Zone Program Integrity Contractor. This program combats fraud, waste, and abuse. Their audits are not random and are performed when fraud or abuse is suspected.

Question 28

What is MIC?

Answer 28

Medicaid Integrity Contractor. This is an audit program mandated by the Deficit Reduction Act of 2005. This program reviews Medicaid claims, performs audits, identifies overpayments, and educates providers.