Fee-for-Service Benefits

As a front office staff member, or a person who receives initial beneficiary information, there are four major tasks you must perform that are vital to the efficiency and financial welfare of the health care organization of which

you are a part.

Copying the Medicare card

Obtaining essential information through use of completed medical information/history and insurance forms

Determining Medicare eligibility

Informing the beneficiary about HIPAA

Benefits that require patients to pay a deductible (if deductible not previously met) and any applicable co-insurance each time a service is rendered. Patients are also responsible for paying non-covered services (program exclusion), or any items for which they signed an Advance Beneficiary Notice (ABN). These benefits allow beneficiaries to go to almost any doctor, hospital, or other health care provider they desire. Generally, a fee is charged to the patient each time a service is rendered by a provider (e.g., co-insurance, Medicare deductible, costs for Medicare non-covered services, or costs of services which are the result of a Written Advanced Notice.)

Note: To close window and return to the course, click the x in the upper right hand corner or press Ctrl + W on your keyboard.

Note:

Advance Beneficiary Notice (ABN)

A notice that a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment. If the beneficiary does not get an ABN before receiving the service, and Medicare does not pay for it, then the beneficiary probably does not have to pay for it. If the doctor or supplier does give the beneficiary an ABN that the beneficiary signs before receiving the service, and Medicare does not pay for it, then the beneficiary will have to pay the doctor or supplier for it. ABNs only apply the beneficiary is in the Original Medicare plan. They do not apply if the beneficiary is in a Medicare Managed Care Plan or Private Fee-for-Service plan.

Mandatory for every patient to sign (ABN)

The rule of the thumb is we provide you the service, you are responsible for payment.

Copying the Medicare Card

it is very important that you obtain a copy of a beneficiary's card during the first visit to your

office.

Medicare also recommends that you periodically verify a beneficiary's insurance information to determine if any changes in the name,

Medicare claim number or other information have occurred. If changes have occurred, the beneficiary's records should be updated

accordingly.

Determining Medicare Coverage Ask the beneficiary questions to make sure you have complete and correct information about their insurance coverage. 1. On [INSERT TODAY'S DATE] are you employed?

2. Are you receiving any group health coverage from an employer for whom you now work?

3. Are you receiving Black Lung (Coal Miner's) Medical Benefits?

4. Are you now receiving any medical services related to an illness or injury, which occurred on the job, for which you have or will file a worker's compensation claim?

5. Are you now receiving treatment for an illness or injury for which another party could be held responsible or could be covered under no-fault, automobile, or liability insurance?

6. On [INSERT TODAY'S DATE] is your husband/wife is employed?

7. Does your husband/wife have group health coverage through his/her employment?

8. Are you receiving group health coverage through a parent or guardian's employer?

For the complete Medicare Secondary Payer (MSP) information, search the MLN Publications web page on the CMS website.

The pieces of information that you need to pay close attention to and record from the

beneficiary's card are listed below and include:

Note: Make sure you use the name of

the beneficiary as it is typed on his/her card on all Medicare records and forms. The name on the card may be slightly different from how the beneficiary signs his/her name.

Type of Medicare coverage (Part A, B, or both)

Name of Beneficiary (exactly as it appears on the card)

Eligibility start date for Medicare coverage

Medicare Claim number

The information that is essential to proper claims processing on the sample Medicare

card is:d

A. Name circled on the card

B. Medicare claim number circled on the card

C. The words health insurance circled on the

card

D. Part A and Part B circled on the card

E. Dates circled on the card

You selected A, B, C, D, E. The information on the sample Medicare card that is essential to proper claims processing is: A. (Name circled on

the card B). (Medicare claim number circled on the card) D. (Part A and Part B circled on the card) E. (Dates circled on the card)

Policy

We will submit the insurance claim for payment

When a beneficiary has a Medigap policy or Medicaid coverage, Medicare is clearly the primary payer.

However, Medicare is the secondary payer to insurance plans and programs under certain circumstances. These circumstances include, but are not limited to:

It is part of your job as a front office staff member

to help determine whether Medicare is the primary or secondary payer of expenses for a claim. The following situations show where Medicare is the primary payer and where Medicare is the secondary payer.

The following chart shows when Medicare is the primary or secondary payer for beneficiaries in a variety of coverage situations and medical care needs.

Beneficiary Situation Medicare as Primary Payer

Medicare as Secondary Payer

Beneficiary has Part B entitlement only

X

Disability

X

Individuals age 65 and over who have Group Health Plan (GHP) coverage as a result of their own current

employment status or the current employment status of a spouse of any age.

Beneficiaries entitled to Medicare solely on the basis of End Stage Renal Disease who are in a 30 month

coordination period.

Disabled beneficiaries covered under a Large Group Health Plan through their own active employment or that

of a family member.

Beneficiaries who suffer an accident that may be covered under No-Fault, Med-Pay or Liability insurance.

Beneficiaries covered under Workers' Compensation or Black Lung.

End Stage Renal Disease

X

Liability

X

Medicaid X

Medigap X

No-Fault

X

TRICARE X

TRICARE for Life X

Workers' Compensation/Black Lung

X

Working Aged

X

When Medicare is clearly the secondary payer, the provider's organization should follow these two steps:

1. File the claim with the primary insurance (Employer Group Health Plan, workers' comp, etc.) first.

2. Attach copies of the payment report, check, etc., once received from the primary insurance company, to the Medicare

claim form. Be sure the attached information includes the amounts allowed and paid by the primary insurer.

Many Medicare contractors now accept MSP claims electronically. Check with your local contractor about the options available

to your organization filing MSP claims.

In liability cases where the beneficiary's medical expenses may be covered by a third party's insurance, the provider has a

choice of actions.

Providers should never bill both Medicare and a liability insurer at the same time. This is double billing and is in violation of

Medicare participation agreements. The provider must either bill the liability insurer directly, or file a lien against the

settlement and bill Medicare for conditional payment.