medicare 101 understanding medicare final

MEDICARE 101: Understanding CMS

Speaker: Tara Ritter-Sellers, CPC, CPC-H, CPC-I

INTRODUCTION TO THE MEDICARE PROGRAM

CHAPTER 1

Chapter 1Pre-Assessment

33

Introduction to the Medicare Program

Largest health insurance programOver 1 billion claims annuallyOver 44 million individuals entitled

44

Identifying Beneficiaries

Health insurance card contains - Name

- Sex - Medicare Health Insurance Claim number - Date of entitlement

55

6

Medicare Card (front)

Jane Doe

Introduction to the Medicare Program

4 parts- Part A, hospital insurance- Part B, medical insurance- Part C, Medicare Advantage- Part D, prescription drug plan

77

8

You have choices in how you get your Medicare health and drug coverage

Medicare has Four Parts

Part A –Hospital Insurance

Helps cover inpatient care in hospitals and skilled nursing facilities, hospice and home health care.

Part B – Medical Insurance

Helps cover doctors’ services, outpatient care, home health care and some preventive services.

Part C – Medicare Advantage Plans

Another way to get Medicare benefits.Combines Parts A and B. Usually includes Part D coverage. Run by private insurance companies approved by and under contract with Medicare.

Part D – Medicare Prescription Drug Coverage

Helps cover the cost of prescription drugs. Run by private insurance companies approved by and under contract with Medicare.

Part AHospital InsuranceInpatient hospital careInpatient care in a Skilled Nursing Facility

following covered hospital staySome home health careHospice care

99

Part BMedical InsurancePhysician and practitioner servicesHome health careAmbulance servicesClinical laboratory and diagnostic servicesSurgical suppliesDurable medical equipment, prosthetics,

orthotics, and suppliesHospital outpatient services

1010

Medicare Part A and Part B Eligibility

Aged insuredAged uninsuredDisabled insuredEnd-Stage Renal Disease insured

1111

Part C Medicare Advantage

Organizations contract with CMS to furnish or arrange for provision of health care services to beneficiaries who- Are entitled to Part A and enrolled in Part B- Permanently reside in service area of Plan- Elect to enroll in Medicare Advantage Plan

1212

Part DPrescription Drug Plans

All who elect to enroll are covered Standard coverage or low income subsidiesHigher income people pay higher Part D premium

Modified adjusted gross income is above a certain amount

Uses same thresholds used to compute income-related adjustments to the Part B premiumAs reported on your IRS tax return from 2 years ago

Effective January 2011

13

ACASection 3308

13

Income-Related Adjustment to Part D PremiumBase beneficiary Part D premium increases

People with incomes above the thresholds used to compute income-related adjustment to Part B premiums

14

ACASection

3308

If your Yearly Income in 2009 was In 2011 You PayFile Individual Tax Return File Joint Tax Return$85,000 or below $170,000 or below Base Premium$85,001–$107,000 $170,001–$214,000 Higher premium$107,001–$160,000 $214,001–$320,000 Higher premium$160,001–$214,000 $320,001–$428,000 Higher premiumabove $214,000 above $428,000 Higher premium

Organizations ThatImpact Medicare

Social Security AdministrationOffice of Inspector GeneralQuality Improvement OrganizationsState Health Insurance Assistance Program

1515

Recent Laws That Impact Medicare

Medicare Improvements for Patients and Providers Act of 2008

Medicare, Medicaid, and State Children’s Insurance Program Extension Act of 2007

1616

Patient Protection and Affordable Care Act (PPACA)

Signed into law H.R. 3590 on March 23, 2010Makes numerous statutory changes to Medicare program

The Health Care and Education Reconciliation Act of 2010 (HCERA)

Signed into law H.R. 4872 on March 30, 2010Modifies PPACA and adds several new provisions

Together called the Affordable Care Act

17

New Legislation – Health Reform

Highlights of Affordable Care Act

Closes prescription drug coverage “Donut Hole”

Strengthens the financial health of MedicareInvests in fighting waste, fraud, and abuseWill extend the financial health of Medicare by

12 yearsChanges annual enrollment period for MA and

PDP Improves preventive services coverage

Lower costsFree annual wellness check-ups starting in 2011

18

Highlights of Affordable Care Act (continued)

Promotes better care after a hospital dischargeCreates the Center for Medicare & Medicaid

InnovationHelp for early retirees (before age 65)

Temporary program to offset cost of expensive premiums

Help for people with pre-existing conditionsHealth insurance through temporary high-risk

pools In 2014, insurance companies can’t deny

coverage

19

Highlights of Affordable Care Act (continued)

Extends dependent coverage to age 26 Eliminates limits on benefitsProvides $11B for Federally Qualified Health

CentersOutpatient primary care and preventive services“Safety net” providers

Community health centersPublic housing centersOutpatient programs funded by the Indian Health

ServicePrograms serving migrants and the homeless

20

ACA Section

1001

Let's Review

What are Medicare’s 4 parts?Medicare Part A and Part B are available to

what 4 groups of individuals?

2121

BECOMING A MEDICARE PROVIDER OR SUPPLIER

CHAPTER 2


2323

Part A Providers and Suppliers

Inpatient Rehabilitation

FacilitiesLong Term Care Hospitals Rural Health ClinicsSkilled Nursing

Facilities

•Critical Access Hospitals•Federally Qualified • Health Centers•Home Health Agencies•Hospice•Hospitals (acute care inpatient)

24

Part B Providers and Suppliers

Ambulances service suppliers

Ambulatory Surgical Centers

Comprehensive Out- patient Rehabilitation Facilities

End-Stage Renal Disease Facilities

Home Health Agencies (outpatient Part B)

Hospitals (outpatient)Nurse practitionersOther non-physician

practitionersPhysiciansSkilled Nursing Facilities (outpatient)

25

Medicare PhysiciansDoctors of medicine and osteopathy, dental

surgery or dental medicine, podiatry or surgical chiropody, optometry

ChiropractorsLegally authorized to practice by State

26

Interns and Residents

Participate in approved Graduate Medical Education programs

Not in approved programs, but authorized to practice only in hospital settingAlso includes interns, residents, and fellows in

programs approved for purposes of direct Graduate Medical Education and Indirect Medical Education payments

27

Teaching Physicians

Involve residents in care of their patientsPresent during all critical or key portions of

procedure Immediately available to furnish services

during entire service

28

Practitioners

Physician assistants

Nurse practitionersClinical nurse specialistsCertified registered nurse anesthetists

Certified nurse midwives

Clinical psychologistsClinical social workersRegistered dieticians

or nutrition professionals

Legally authorized to practice by State Legally authorized to practice by State and otherwise meets Medicare and otherwise meets Medicare requirementsrequirements

29

Enrolling in MedicareObtain National Provider Identifier Complete Medicare Enrollment Application

3030

Enrolling in MedicareInclude with Medicare Enrollment Application

- Forms CMS-588 and CMS-460

- CMS Standard Electronic DataInterchange Enrollment Form

- State medical license- Occupational or business license- Certificate of Use

3131

Participating Provider/Supplier

Accepts assignmentAccept the Medicare-approved amount

As full payment for covered services Only charge Medicare deductible/coinsurance amount

They submit your claim to Medicare directlyApplies to Original Medicare Part B claimsWe say “accepts assignment”

1 year participation period

3232

Participating Provider/Supplier Benefits

Higher Medicare Physician Fee Schedule allowances Limiting charge provisions not applicable Included in Physician and Other Healthcare Professional Directory

3333

Nonparticipating Provider/Supplier

May accept assignment of claims on claim-by-claim basis

Held to limiting charge on nonassigned claimsMay collect up to the limiting charge

“Limiting Charge” means the physican can only charge you up to 15% over the Medicare-approved amount.

The limiting charge applies only to certain services and doesn’t apply to some supplies and durable medical equipment.

3434

Limiting Charge Example

MPFS Allowed Amount for Procedure “X”

Nonparticipating Provider/Supplier Allowed Amount for Procedure “X”

Limiting Charge for Procedure “X”

Beneficiary Coinsurance and Limiting Charge

PortionDue to Provider/Supplier

$200.00

$190.00

$218.50

$ 66.50

3535

Payment Amounts Example

36

Participating Provider/Supplier

NonparticipatingProvider/SupplierWho AcceptsAssignment

Nonparticipating Provider/Supplier Who Does Not Accept Assignment

Submitted $125.00 $125.00 $109.25Amount

MPFS Allowed $100.00 $ 95.00 $ 95.00Amount

80 Percent of $ 80.00 $ 76.00 $ 76.00MPFS Allowed Amount

Beneficiary $ 20.00 $ 19.00 $ 33.25Coinsurance

Total Payment $100.00 $ 95.00 $109.25 ($95.00 x 1.15To Provider/ limiting charge)Supplier

36

Cultural Competency

Addressing a patient’s social and cultural background assists in delivering high quality, effective health care

37

Let's Review

What are the steps that must be taken in order to enroll in and obtain reimbursement from Medicare?

What are the benefits of becoming a Medicare participating provider or supplier?

38

CHAPTER 3

MEDICARE REIMBURSEMENT


4040

Medicare Claims

Must submit claims for services Cannot charge for completing or filing claimFile on or before December 31 of year

following year services furnished

4141

Exceptions to Mandatory FilingCertain secondary payer claims Services furnished outside the U.S.Services initially paid by third-party insurersClaims for unusual or excluded servicesClaims when provider/supplier opted out,

excluded, or debarred

4242

Electronic ClaimsClaims must be submitted electronically,

except in limited situations, using - Electronic media claims- Electronic billing software vendor or clearinghouse- Billing agent- Medicare’s free billing software

4343

Deductible, Coinsurance, and Copayment

Deductible – amount beneficiary must pay before Medicare begins to pay

Coinsurance – percentage of covered charges beneficiary may pay after meeting deductible

Copayment – amount beneficiary pays for each medical service

4444

Medicare Secondary Payer

Must determine whether Medicare is the primary or secondary payer prior to submitting a claim

Coordination of Benefits Contractor – provides assistance to providers and suppliers

4545

Incentive/Bonus Payments

Health Professional Shortage Area Incentive Payment – 10 percent

Physician Scarcity Area Bonus Payment – 5 percent

4646

Medicare Physician Fee Schedule

Basis for payment of physician services under Medicare Part B

3 components

- Relative Value Units - Conversion Factor

- Geographic Practice Cost Indices

4747

Medicare Notices

Advance Beneficiary NoticeCertificate of Medical Necessity and

Durable Medical Equipment Medicare Administrative Contractor Information Forms

Remittance AdviceMedicare Summary Notice

4848

Other Health Insurance Plans

Medicare AdvantageMedicaidMedigap

4949

Let's ReviewWhat is a Health Professional Shortage Area

incentive payment?What is the Advance Beneficiary Notice?

5050

MEDICARE PAYMENT POLICIES

CHAPTER 4


5252

Medicare Covered Services

Services and supplies must be medically necessary

Proper and needed for diagnosis or treatment of medical condition

Furnished for diagnosis, direct care, treatment of medical condition

Meet standards of good medical practice Not mainly for convenienceSome Preventive Health Care Services

5353

54

Covered Preventive Services

One time “Welcome to Medicare” physical exam

Physical Exam (yearly “Wellness Exam”) Starts 2011

Abdominal aortic aneurysm screening*

Bone mass measurementCardiovascular disease

screeningsColorectal cancer

screeningsDiabetes screenings

EKG Screening*Flu shots Glaucoma testsHepatitis B shotsHIV ScreeningMammograms (screening)Pap test/pelvic

exam/clinical breast examProstate cancer screeningPneumococcal shotsSmoking cessation

*When referred during Welcome to Medicare physical exam

Health

Reform

Section

4103

Part A Inpatient Hospital Services

Bed and boardNursing and related

servicesUse of hospital or

Critical Access Hospital

facilitiesMedical social servicesDrugs, biologicals,

supplies, appliances, and equipment

Diagnostic or therapeutic services

Medical or surgical services furnished by interns or residents in training

Transportation services

5555

Part B Services

Surgery, office visits, and institutional calls

Services, supplies, and outpatient hospital services furnished incident to physician services

Outpatient physical, occupational, and speech-language pathology services

Diagnostic servicesAmbulance servicesPreventive services

5656

Incident to Physician ServicesCommonly furnished in physicians’ offices or

clinicsFurnished by physician or auxiliary personnel

under direct personal supervision of physicianFurnished without charge or included in

physician’s billIntegral, although incidental, part physician’s

professional service

57

Services not Covered by Medicare

Excluded servicesServices considered not medically necessary Services denied as bundled or included in basic

allowance of another serviceIn addition, Medicare does not pay for claims

rejected as “unprocessable”

58

Let's Review

What are medically necessary services and supplies?

What services are not covered by Medicare?

5959

EVALUATION AND MANAGEMENT

DOCUMENTATION

CHAPTER 5


6161

Background – Evaluation and Management Documentation

Translates patient care work into claimsand reimbursement mechanism;

accuracyis critical inEnsuring correct payment for workSupporting correct evaluation and

management code levelProviding validation for medical review

6262

Medical Record DocumentationRecords pertinent facts, findings, and

observations about patient’s health history

Facilitates

- Evaluating and planning treatment and

monitoring treatment and health of patient- Communication and continuity of care- Claims review and payment- Utilization review and quality of care evaluations- Collection of data

6363

7 General Principles of Documentation

1. Medical record should be complete and legible

2. Each encounter should include- Reason for encounter and relevant history, physical examination findings, and prior test results- Assessment, clinical impression, or diagnosis- Plan for care- Date and legible identity of observer

6464


3. Rationale for ordering diagnostic tests and ancillary services should be easily inferred if not documented

4. Past and present diagnoses accessible to treating and/or consulting physician

5. Appropriate health risk factors identified

6565


6. Patient’s progress, response to and changes in treatment, and revision of diagnosis documented

7. CPT and ICD codes reported on health insurance claim form or billing statement supported by documentation in medical record

6666

Levels of Evaluation and Management Services

HistoryExaminationMedical decision

making

CounselingCoordination of careNature of presenting

problemTime

6767

3 Key Components (HEM) Procedure History Examination Medical

Decision Making Code 99201® Problem Focused Problem Focused Straightforward

99202 Expanded Expanded Straightforward Problem Focused Problem Focused

99203 Detailed Detailed Low Complexity

99204 Comprehensive Comprehensive Moderate Complexity

99205 Comprehensive Comprehensive High Complexity

CPT only copyright 2008 American Medical Association. All rights reserved.

6868

History

4 levels- Problem Focused- Expanded Problem Focused- Detailed- Comprehensive

Elements- Chief complaint- History of present

illness- Review of systems- Past, family,

and/or social history

6969

HistoryHPI ROS PFSH Level of

History

Brief N/A N/A Problem Focused

(1 – 3 elements)

Brief Problem Pertinent N/A Expanded Problem Focused

(1 – 3 elements)

Extended Extended Pertinent Detailed(4 or more elements)

Extended Complete Complete Comprehensive(4 or more elements)

Elements: ROS: PFHS areas:location, quality, constitutional, eyes, ears past historyseverity, duration, nose, mouth, throat, family historytiming, context, cardiovascular, respiratory, social historymodifying factors, gastrointestinal, gastro- associated signs urinary, musculoskeletaland symptoms integumentary, neuro-

logical, psychiatric, endocrine, hematologic/ lymphatic, allergic/ immunologic

7070

Examination

4 types- Problem Focused- Expanded Problem Focused- Detailed- Comprehensive

General multi-system or single organ system

7171

General Multi-System Examination Level of Examination Perform and Document

Problem Focused 1– 5 elements identified by a bullet in 1 or more organ system(s) or body area(s)

Expanded Problem At least 6 elements identified by a bullet in 1 orFocused more organ system(s) or body area(s)

Detailed At least 2 elements identified by a bullet fromat least 6 organ systems or body areas or atleast 12 elements identified by a bullet in 2 ormore organ systems or body areas

Comprehensive All elements identified by a bullet in at least9 organ systems or body areas; for each

system/area, at least 2 elements identified by a

bullet

7272

Single Organ System Examination

Level of Examination Perform and Document

Problem Focused 1 – 5 elements identified by bullet in box with

either shaded or unshaded border

Expanded Problem At least 6 elements identified by bullet in box

Focused with either shaded or unshaded border

Detailed At least 12 elements identified by bullet in box with either shaded or unshaded border (except

eye and psychiatric examinations)

Comprehensive Perform all elements identified by bullet in box with either shaded or unshaded border; document every element in each box with

shaded border and at least 1 element in box

with unshaded border

7373

Medical Decision Making

Straightforward Low complexity Moderate complexity High complexity

7474

Medical Decision Making

Number of Amount and/or Risk of Type of Medical

Diagnoses/ Complexity of Complications, Decision Making

Management Data to be Morbidity, and/or Options Reviewed Mortality

Minimal Minimal or None Minimal Straightforward

Limited Limited Low Low Complexity

Multiple Moderate ModerateModerate

Complexity

Extensive Extensive High High Complexity

7575

New Patient Visit

Procedure History Examination Medical Decision Making

Code 99201® Problem Focused Problem Focused

Straightforward

99202 Expanded Expanded Straightforward Problem Focused Problem Focused

99203 Detailed Detailed Low Complexity

99204 Comprehensive Comprehensive Moderate Complexity



7676

Established Patient VisitProcedure History Examination Medical

Decision Code Making99211® N/A N/A N/A

99212 Problem Focused Problem Focused Straightforward

99213 Expanded Problem Expanded Problem Low Complexity Focused Focused

99214 Detailed Detailed Moderate Complexity



7777

Let's ReviewWhat are the 7 components that define the levels of evaluation and management services?

HistoryExaminationMedical Decision MakingCounselingCoordination of CareNature of Presenting ProblemTime 7878

PROTECTING THE MEDICARE TRUST

FUND

CHAPTER 6


8080

Medical Review Program

Analyze data Take action to prevent and/or address identified errors Publish local medical review policies

8181

National Coverage Determination

Identifies extent to which Medicare covers specific services, procedures, or technologies on national basis

8282

Local Coverage Determination

Developed to further define a National Coverage Determination or in absence of a specific National Coverage Determination

Made at Contractor’s discretion to provide guidance to public and medical community within specified geographic area

8383

Deterring Health Care Fraud and Program Abuse

Identify suspicious Medicare charges and activities

Investigate and punish those who commit Medicare fraud and abuse

Ensure money is returned to Medicare Trust Fund

8484

Federal Health Care Fraud Intentional use of false statements or fraudulent schemes to obtain payment for, or to cause another person or entity to obtain payment for, items or services payable under a Federal health care program

8585

Program Abuse Intentional or unintentional Directly or indirectly results in unnecessary or

increased costs to the Medicare Program

8686

Potential Legal Actions

Fine Prison sentence Temporary or permanent exclusion from

Medicare or other health care programs Lose license Civil Monetary Penalties

8787

Potential Legal Actions

Deny individual or entity’s application for Medicare provider billing privileges

Revoke provider’s billing privileges Suspend payment Exclusion from participation

8888

Report SuspectedFraud or Abuse

Office of Inspector General TIPS Hotline – (800) 447-8477E-mail – [email protected] Fax – (800) 223-8164

8989

Let's ReviewWhat are the 2 types of coverage

determinations that assist providers and suppliers in coding correctly and billing Medicare only for covered items and services?

What is program abuse?

9090

INQUIRIES, OVERPAYMENTS,

AND APPEALS

CHAPTER 7


9292

Inquiries

Submit by telephone or in writing Interactive Voice Response Services

9393

Overpayments

Funds that a provider, supplier, or beneficiary received in excess of amounts due and payable

9494

5 Levels of Fee-For-Service Appeals First level – Redetermination by Medicare

Contractor Second level – Reconsideration by Qualified

Independent Contractor Third level – Hearing by Administrative Law

Judge Fourth level – Medicare Appeals Council

Review Fifth level – Judicial Review

9595

Reopening

Remedial action to change a final determination or decision that resulted in an overpayment or an underpayment

Allows correction of minor errors or omissions without initiating a formal appeal

9797

Let's ReviewUnder what circumstances are overpayments

often paid?What are the 5 levels in the appeals process?

9898

Post-Assessment Course Evaluation

Evaluation of course will be sent via emailCompletion of evaluation requiredThank you for your feedback

9999

medicare 101 understanding medicare final

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