Week 3 Flashcards
What is the eligibility for medicare?
65 years of age or older
disabled, any age received SS benefits for at least 2 years
people with end stage renal disease or ALS
medicare part A
hospital
some skilled nursing facilities
home health and hospice care
medicare part B
physician and other health care provider services
outpatient
durable medical equipement
home health care
medicare part C
advantage plans (offers part A&B benefits and sometimes D
medicare part D
perscripton drug coverage
chiroparactic services are generally covered under what parts of medicare?
B and C
how do you enroll in medicare?
register
need an NPI
need to revalidate every 5 years
participating provider
agree to accept assignment for all covered services taht you provide to medicare patients
why should you participate in medicare?
medicare fee schedule amounts are 5% higher if you participate
providers receive direct and timely reimbursement from medicare
medgap insurer must pay participant directly
what does being a participating provider mean?
signed agreement/contract with Medicare
payments are made directly to the provider
accept assignment on ALL claims
provider listed in the medicare provider directory
secondary insurance is automatically billed
medicare fees schedules are up to 5% high if you participate
can you change from par to non-par?
yes
only in open enrollment period
generally from mid-November to December 31st
what does being non-par entail?
you still have to bill medicare
“mandatory claim submission rule”
what is non-par?
someone who has enrolled to be a medicare provider but chooses to receive payment in a different method and amount than par
what does it mean to be non-par?
enrolled in the medicare program
no signed agreement with medicare regarding payment
may choose to accept or not accept assignement
non-assigned claim payments go to the patient
secondary insurance is billed by provider
charges can’t be more than the limiting charge
provider not listed in the medicare provider directory
how can you determine if you are properly registered with medicare?
you will have an NPI
how does medicare payment work?
par= bill medicare and the medigap insurer will pay you non-par= goes to patient
what are MACs and how do they function?
medicare administrative contractor
has jurisdiction to process medicare part A and B medical claims (or DME claims for medicare fee for service (FFS) beneficiaries)
what are the parts of medicare part c?
HMO
PPO
PFFS
SNP
HMOPOS
point of service plans
similar to HMOs, but you may be able to get some services out of network for a higher cost
MSA
medical savings accounts
a high deductible plan combined with a bank account
medicare deposits funds to this account and benefiiary uses the money from that accound to pay for healthcare services
MAC
produce local coverage determinations (LCDs)
LCD
a contract and what you will agree to if you take any medicare patients in the jurisdiction MAC handles
services are reasonable and necessary if..
safe and effective
not experimental or investigational
appropriate, including duration and frequency that is considered for the service
furnished in accordance with the accepted standards of medical practice
furnished in a setting appropriate to the patient’s medical needs
ordered and furnished by qualified personnel
one that meets, but doesnn’t exceed patient’s medical need
at least as beneficial as an existing and available medically appropriate alternative
what questions should you ask yourself if you’re wondering if medicare will pay?
is the patient a medicare beneficiary?
what services were rendered?
is the purpose of the visit for maintenance or active therapy?
is there sufficient supporting documentation to justify the services?
what must active care provide?
reasonable expectation of recovery or improvement of function
maintenance care
further clinical improvement cannot reasonably be expected from continuous, ongoing care and the chiropractic treatment has become supportive rather than corrective in nature
is maintenance care reimbursable under medicare?
no
advanced beneficiary notice
used to let patients know that there will be a charge medicare will not pay
is an ABN used often?
no
what is coded first for medicare?
subluxation
