Medicare

Question 1

What does Medicare not cover?

Answer 1

Dental, hearing aids, eyeglasses, custodial care

Question 2

High cost-sharing requirements

Answer 2

Deductibles for Parts A, B, D
Coinsurance, copayments
Part D coverage gap

Question 3

Medicare Etc

Answer 3

No limit on out of pocket spending

Pays about half of beneficiaries total health and long term care spending

Question 4

Medicare Part A

Answer 4

Hospital Insurance: inpatient care (acute and SNF), home health, inpatient rehab, hospice

Question 5

Medicare Part B

Answer 5

Medical Insurance/Outpatient

Question 6

Medicare Part C/ Advantage

Answer 6

Try to add market forces to the program

Run by private companies

Question 7

Medicare Part D

Answer 7

Drug benefit
Replaced no drug coverage in the MMA of 2003
Written directly by the pharmaceutical companies

Question 8

A and B

Answer 8

Part A uses PPS
Provider charges Medicare for services it has provided to medicare beneficiary
Medicare pays them for service based on a fee schedule through a 3rd party administrator called a MAC

Question 9

What is a Diagnosis Related Grouping (DRG)?

Answer 9

Get a set amount for an illness. If the pt is D/C’d then returns later, they get another set of money to treat the pt so theyre incentive to spend more time with them

Question 10

Health Reform (Fee for Service)

Answer 10

Encourages more services
More expensive services
Rewards specialists, not PCP
Does not encourage prevention

Question 11

Part A Acute Care Hospital Benefit

Answer 11

No premium unless worked more than 40 quarters
Hospital deductible (1216)then paid fully x 60 days of illness
60-90: 304/day
90-150 days: 608/day
No coverage after 150 days
No out of pocket maximum

Question 12

Prospective Payment System (PPS)

Answer 12

Funding model replaces FFS
Fixed amount payment to provider/institution for each admission
Used in multiple settings
Started in acute care (DRGs)
Home health and SNF PPS began with BBA of 1997, put in place in 1999

Question 13

Diagnosis Related Group (DRG)

Answer 13

A type of PPS
Classifies hospital cases in 500 groups
Incentive for quick d/c
Minimization of costly care
Minimization of staffing levels
Shorter hospital stays, more post-acute care
Sicker and more disabled upon discharge

Question 14

SNFs

Answer 14

Medicare pays for temporary housing

custodial care is Part B

Question 15

Part A SNF coverage

Answer 15

Day 1-20: no coinsurance/cost-sharing
20-100 days: 152/day
After 100 days no coverage

Question 16

Qualify for SNF

Answer 16

Inpatient who needs skilled nursing care or other rehab services on a daily basis
Prior hospital stay within 30 days
SNF PPS=RUG Levels=MDS

Question 17

SNF PPS

Answer 17

Facilities are paid a lump per diem rate based on RUG levels (case mix)
Covers medications, supplies, nursing, rehab, etc

Question 18

RUG Levels

Answer 18

Resource Utilization Group/Case Mix
AKA MDS 3.0 or RUG IV
66 RUG Groups

Question 19

MDS 3.0 Minimum Data Set

Answer 19

Info on nursing needs, ADL impairments, cognitive status, behavioral problems, medical diagnoses
Determines which case mix/RUG level which determines payment

Question 20

Ultra high RUG Group

Answer 20

Use most resources, facility gets paid more to have them since more expensive, needs more minutes of therapy. Can be risky only taking ultra high
Classify pts as high as possible

Question 21

Home Health Care

Answer 21

Homebound
Under care of physician
Requires skilled care of nursing, PT, or speech
Prior 3 day hospitalization
OASIS documentation form

Question 22

Inpatient Rehab Facilities Requirements

Answer 22

Clincally stable
Able to tolerate at least 3 hours of rehab (combined PT, OT, speech) at least 5x/wk
75% rule

Question 23

Medicare and IRFs

Answer 23

Medicare pays IRFs a higher rate then hospitals/SNFs due to specialized rehab

Question 24

75% Rule

Answer 24

Focus on medical necessity and functional capability

75% must be in one of 13 categories. If 75% of ppl in IRF meet the category, then new pt can have any problem

Question 25

Implementation/freeze

Answer 25

2010 ruled a permanent freeze at 60%, so a minimum of 60% of admissions must meet critieria, not 75% Caused some IRFs to close, SNFs had increased pt use

Question 26

Part A Finance

Answer 26

1.45% payroll on workers Matched by employer Self-employed paid full amt Must work 10 years to qualify

Question 27

Part B: Supplemental Medical Insurance

Answer 27

``` Physician services Outpatient care including outpatient PT Ambulance services Preventative services Lab/diagnostic testing ```

Question 28

Part B Coverage

Answer 28

Premium 104 if make under 85000/yr Deductible 147/yr Coinsurance of 20% Medicare approved amt

Question 29

GA Modifier

Answer 29

ABN (advanced beneficiary notice) in place | Means pt is aware that they will have to pay if the service is not covered by Medicare

Question 30

59 Modifier

Answer 30

CCI (Corrective Coding Initative) Edit Exception

Question 31

Part B Therapy Cap

Answer 31

PT and SLP combined $1920

Question 32

Automatic Exception

Answer 32

Manual exception no longer exists. KX modifier used. Need documentation Significant ability to provide services above the cap, must meet requirements Example: if pt uses all 1920 for one diagnosis then gets another diagnosis they get a new 1920, must use a KX modifier in exemption

Question 33

Multiple Procedure Payment Reduction (MPPR)

Answer 33

Payment reduction when multiple CPT codes billed on same date of service Part B Resulted in cuts to PT and others since its the number of codes, not types

Question 34

ABN (Advanced Beneficiary Notice)

Answer 34

Notice saying Medicare may not pay for certain services and that the Beneficiary may need to pay if they want the service

Question 35

CCI Edits (Correct Coding Initiative)

Answer 35

Ensures most comprehensive groups of codes are billed rather than component parts Checks for mutually exclusive code pairs Bill for what Medicare will most likely bill for if there is overlap

Question 36

CCI 59 Modifier

Answer 36

Certain codes are prohibited from being billed on the same day. Add 59 modifier to indicate that services were performed during different time intervals. Don't bill a modifier on every claim

Question 37

Medicare Direct Access

Answer 37

Don't need a referral, but need a physician to sign a Plan of Care

Question 38

Part B Funding

Answer 38

Premium withheld from Social Security check Premiums cover 25% of plan 75% comes from tax revenues

Question 39

Supplemental Coverage (Part C)

Answer 39

88% beneficiaries get supplemental coverage in addition to Parts A and B

Question 40

Types of Supplemental Coverage

Answer 40

Medigap Plan Medicaid supplement Employer Sponsored Medicare Advantage/Part C

Question 41

Part C

Answer 41

Wants to enroll young healthy ppl since costs will be lower (favorable selection)

Question 42

Part D

Answer 42

Partial drug coverage Subsidizes costs of prescription drugs for Medicare beneficiaires Part of Medicare Prescription Drug Improvement Act (MMA) of 2003 Coverage is all by private insurers with little regulation

Question 43

Medicare Administrative Contractors (MAC)

Answer 43

Single contracted payer to enforce regulations and coordinate payment for services

Question 44

Recovery Audit Contractors (RACS)

Answer 44

Contract with federal government to identify fraud and recover overpayment of funds

Question 45

National Coverage Decision (NCD)

Answer 45

Decision made at federal level broadcasted nationally to providers about what is covered if a benefit is not clear

Question 46

Local Coverage Decision (LCD)

Answer 46

Coverage decision made by contractor (MAC), cannot override NCD

Question 47

Supplemental Security Income (SSI)

Answer 47

NOT MEDICARE Monthly amt paid by social security, gives money to ppl with limited income and resouces to buy food, clothing, shelter SSI benefits not same as social security benefits Person must be disabled, blind, age 65 or older and unable to work