Medicare

Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over, or who meet other special criteria. Cahaba is the Medical Center's Medicare Administrative Contractor

Medicare is a health insurance program for: people age 65 or older, people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant) Medicare has: Part A Hospital Insurance Part B Medical Insurance Part C Medicare Advantage Part D Prescription Drug Coverage

What Does Part A Cover? Inpatient care in hospitals (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals) Considered an inpatient the day a doctor formally writes an Inpatient admit order Inpatient care in a skilled nursing facility (not custodial or long term care) Hospice care services Home health care services Inpatient care in a Religious Nonmedical Health Care Institution

The patient is responsible for a deductible amount for inpatient hospital services in each benefit period.

The coinsurance amount is based on the deductible applicable for the calendar year in which the coinsurance days occur. The deductible is satisfied only by charges for covered Part A services. Expenses for covered services count toward the deductible on an incurred, rather than paid, basis.

In each benefit period, the patient is responsible for coinsurance amounts equal to: One-fourth of the inpatient hospital deductible for each day of inpatient hospital services from the 61st through the 90th days; One-half of the inpatient hospital deductible for each lifetime reserve day (the 91st through the 150th days of inpatient hospital services); and For any hospital stay that lasts longer than 150 days within a single benefit period, you will be required to pay the full cost for each day after the 150th day.

Durable Medical Equipment (DME) Furnished as a Home Health Benefit The patient is responsible for 20 percent of the payment amount for DME furnished as a home health benefit.

A benefit period begins with the first day (not included in a previous benefit period) on which a patient is furnished inpatient hospital or extended care services by a qualified provider in a month for which the patient is entitled to hospital insurance benefits

The benefit period ends with the close of a period of 60 consecutive days during which the patient was neither an inpatient of a hospital nor of a SNF. To determine the 60 consecutive day period, begin counting with the day the individual was discharged.

It is important to note that a benefit period cannot end while a beneficiary is an inpatient of a hospital, even if the hospital does not meet all of the requirements that are necessary for starting a benefit period. Similarly, a benefit period cannot end while a beneficiary is an inpatient of a SNF That is, the beneficiary cannot have been in a facility that is primarily engaged in providing, by or under the supervision of a physician(s), to inpatient

Part B helps cover medically-necessary services like doctors' services, outpatient care, home health services, and other medical services. Part B also covers some preventive services.

Member will Pay a Part B premium each month. Most will pay the standard premium amount. If a member Does not sign up for Part B when first eligible, member may have to pay a late enrollment penalty.

Part B covers two types of services: Medically-necessary services — Services or supplies that are needed to diagnose or treat a medical condition and meets accepted standards of medical practice. Preventive services — Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

After the deductible has been satisfied, coinsurance of 20 percent is usually applicable There is no deductible for screening mammography effective for services January 1, 1998 and later

Neither the annual deductible nor the 20 percent coinsurance apply with respect to: Parts A and B home health services, except that there is a coinsurance of 20 percent of the payment amount for supplies, drugs, DME and prosthetics /orthotics furnished as a home health benefit; Clinical diagnostic laboratory tests (including specimen collection fees) performed or supervised by a physician, laboratory, or other entity paid on an assigned basis; Pneumococcal vaccine and its administration; Influenza vaccine and its administration; and Services or items denied as medically unnecessary.

Annual Deductible 2013 $147.00 2012 $140.00 ___Expenses count toward the deductible on the basis of incurred, rather than paid expenses, and are based on Medicare allowed amounts. ___Non-covered expenses do not count toward the deductible.

Sometimes called "Part C" or "MA Plans An HMO or PPO plan Will provide all of Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. May offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs Most include Medicare prescription drug coverage (Part D). Always covered for emergency and urgent care

Can charge different out-of-pocket costs and have different rules for how a person can get services Such as needing a referral to see a specialist Such as having to go to only doctors, facilities, or suppliers that belong to the plan for non‑emergency or non-urgent care These rules can change each year

Different Types of Medicare Advantage Plans Health Maintenance Organization (HMO) Plans Preferred Provider Organization (PPO) Plans Private Fee-for-Service (PFFS) Plans Special Needs Plans (SNP)

After December 31, Between January 1-February 14, 2011, if a member has Medicare Advantage Plan, the member can leave the plan and switch to Original Medicare If switching to Original Medicare during this period, member will have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Coverage will begin the first day of the month after the plan gets the enrollment form Member an join a Medicare Advantage Plan even if a pre existing condition exist, except for End-Stage Renal Disease

If the Medicare Advantage Plan (re: United Health Care) decides to stop participating in the Medicare program, member will have to join another Medicare health plan or return to Original Medicare

If a member uses a doctor, facility, or supplier that doesn't belong to the plan, the services may not be covered, or costs could be higher, depending on the type of Medicare Advantage Plan

Medicare Prescription Drug Coverage These plans (sometimes called "PDPs") add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans. If member decides not to join a Medicare drug plan when first eligible, and does not have other credible prescription drug coverage, member will likely pay a late enrollment penalty. Each plan can vary in cost and drugs covered To join a Medicare Prescription Drug Plan, member must have Medicare Part A or Part B. Must also live in the service area of the Medicare drug plan wanting to join.

Violation of the 72 Hour Rule could lead to exclusion from the Medicare Program, criminal fines and imprisonment, and civil liability. Therefore, anyone who observes a violation of the rule should notify their immediate supervisor. You may also confidentially report violations to the Medical Center's Corporate Compliance Helpline (633-6831). Also, the Medicare billing supervisor is required to take and check a random sample of Medicare outpatient claims paid each month

On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA) which amended the time period for filing Medicare fee-for-service (FFS) claims Claims with dates of service on or after January 1, 2010 received more than 1 calendar year beyond the date of service will be denied as being past the timely filing statute (ex: claim DOS = 3/15/10, claim must be received by COB 3/15/11). Electronic Media Claims Improves timeliness Cost effective Eliminates claim submission errors Correct and resubmit Confirmation of receipt Cahaba GBA can receive electronic claims in two ways; Claims can be keyed directly using Direct Data Entry (DDE) Claims can be sent through a file transfer process

Remittance Advice (RA) is a notice of payments and adjustments sent to providers, billers, and suppliers.

ADDING MEDICARE OR MEDICAID TO OUTPATIENT CLAIM OR REBILLING AN OUTPATIENT MEDICARE CLAIM: If adding or rebilling Medicare or Medicaid to any outpatient type or emergency type account, you MUST do the following before Rebilling the account: Go to Post Memo/Chng Collection Data under CAAM and enter Y in the APC Critical Bypass field Anytime a Medicare /Medicaid outpatient or emergency account is re-billed, Y must be entered in the APC Critical Bypass Field. If charges are entered after Medicare or Medicaid has paid on an outpatient account and intend to re-bill the account, enter Y in the APC Critical Bypass Field If adding Medicare or Medicaid as primary payer with intentions to rebill the account, enter Y in the APC Critical Bypass Field If rebilling a Medicare or Medicaid outpatient claim to get a UB04 or for other reasons, enter Y in the APC Critical Bypass Field

An Advance Beneficiary Notice (ABN), also known as a "waiver of liability," is a notice that suppliers and other medical providers are required to give when they offer services or items that are known or have reason to believe Medicare will determine to be medically unnecessary and therefore, will not pay for.

Medicare Part B (Medical Insurance) covers ambulance services to or from a hospital, critical access hospital, or a skilled nursing facility only when other transportation could endanger a patients health.

Performs claim analysis which includes looking at billing trends and patterns across Medicare

Condition Code 44--Inpatient admission changed to outpatient - For use on outpatient claims only, when the physician ordered inpatient services, but upon internal review performed before the claim was initially submitted, the hospital determined the services did not meet its inpatient criteria.

Part A benefits allow for 60 lifetime reserve days for use after a 90-day benefit period has exhausted. The 60 days are not renewable and may be used only once during a beneficiary's lifetime. Inpatient hospital services count toward the maximum of 60 lifetime reserve days under the same conditions as in subsection A except that days are not counted if: The individual elects not to have payment made The coinsurance rate exceeds the daily charge

For institutional care such as hospital and nursing home care, Medicare uses prospective payment systems. A prospective payment system is one in which the health care institution receives a set amount of money for each episode of care provided to a patient, regardless of the actual amount of care used. The actual allotment of funds is based on a list of diagnosis-related groups (DRG). The actual amount depends on the primary diagnosis that is actually made at the hospital. There are some issues surrounding Medicare's use of DRGs because if the patient uses less care, the hospital gets to keep the remainder. This, in theory, should balance the costs for the hospital. However, if the patient uses more care, then the hospital has to cover its own losses. This results in the issue of "up coding," when a physician makes a more severe diagnosis to hedge against accidental costs.

Deductible and Coinsurance amounts: __Inpatient Hospital Deductible, 1st 60 days 2013 $1,184.00 2012 $1,156.00

Deductible and Coinsurance amounts: __Inpatient Hospital Coinsurance, 61st - 90th Day 2013 $296/day 2012 $289/day

Deductible and Coinsurance amounts: __60 Lifetime Reserve Days Coinsurance 2013 $592.00/day 2012 $578.00/day

Deductible and Coinsurance amounts: __SNF Coinsurance 2013 $148.00 2012 $144.50

___Fraud is defined as making false statements or representations of material facts in order to obtain some benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the person's own benefit or for the benefit of some other party. In order to prove that fraud has been committed against the Government, it is necessary to prove that fraudulent acts were performed knowingly, willfully, and intentionally .

-_Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare program. Many times abuse appears quite similar to fraud except that it is not possible to establish that abusive acts were committed knowingly, willfully, and intentionally.

Examples of fraud include, but are not limited to, the following: Billing for services that were not furnished and/or supplies not provided. This includes billing Medicare for appointments that the patient failed to keep Altering claims forms and/or receipts in order to receive a higher payment amount

Following are three standards that CMS uses when judging whether abusive acts in billing were committed against the Medicare program Reasonable and necessary; Conformance to professionally recognized standards; and Provision at a fair price.

Examples of abuse include, but are not limited to, the following: Charging in excess for services or supplies; Providing medically unnecessary services or services that do not meet professionally recognized standards; Billing Medicare based on a higher fee schedule than for non-Medicare patients; Submitting bills to Medicare that are the responsibility of other insurers under the Medicare secondary payer (MSP) regulation; and Violating the participating physician/supplier agreement

A set of questions asked to help determine Medicare Secondary Payer situations which helps prevent Medicare fraudulent billing

Upon each inpatient and outpatient admission for Medicare beneficiaries who have insurance other than Medicare. Providers may use this as a tool to help identify whether other payers may be primary to Medicare.

There are many insurance benefits a patient could have and many combinations of insurance coverage to consider before determining who pays first. Depending on the type of additional insurance coverage, if any, a patient has, Medicare may be the primary payer for a beneficiary's claim(s) or considered the secondary payer.

There are programs under which payment for services is usually excluded from both primary and secondary Medicare benefits. Veteran's Administration (VA) Benefits - Medicare does not pay for the same services covered by VA benefits. For further information about VA benefits contact the VA Administration at 1-800-827-1000. Federal Black Lung Benefits - Medicare does not pay for services covered under the Federal Black Lung Program. However, if a Medicare-eligible patient has an illness or injury not related to black lung, they may submit a claim to Medicare.

Questionnaire Determines payer order for ALL Medicare patients Must obtain all information per CMS standards Must contain the correct answers Must be completed before a claim is filed with Medicare One questionnaire for one face-to-face service Must be retained for a period of at least 10 years

Compliance Must be completed before a claim is filed with Medicare One questionnaire for one face-to-face service Must be retained for a period of at least 10 years

Reason for Entitlement Determines entitlement due to age, disability, or end-stage renal disease (ESRD) At 65, age provisions take over Must allow for dual entitlement Beware of electronic defaults

Age Entitled Medicare entitlement starts the 1st of the month that the patient turns 65. There must be 20 or more employees for an employer's health plan to be primary to Medicare. Must contain the correct answers The patient or the spouse must provide the coverage for it to be primary to Medicare If patients do not recall their retirement dates, defaults are availa

Disability The patient will be under the age of 65 There must be 100 or more employees for an employer's health plan to be primary to Medicare Any family member can provide the coverage for it to be primary to Medicare COBRA is always secondary to Medicare unless...

End Stage Renal Disease The 30-month coordination period determines the payer order Employment data is irrelevant Dual entitlement means that the patient has Medicare due to ESRD and another reason Coverage can terminate, it just can't be secondary

The 72 - Hour Rule is part of the Medicare Prospective Payment System (PPS). The 72 hour rule seeks to prevent fraudulent billing to Medicare. Registration, billing, customer service, and all staff involved with Medicare bills are required to complete annual training over the 72 hour rule.

The rule states that any outpatient diagnostic or medical services performed within 72 hours prior to being admitted to the hospital must be bundled into one bill. Another way of wording the rule is that outpatient services performed within 72 hours of inpatient services are considered one claim and must be billed together rather than separately.

The CFO and CEO are ultimately responsible for compliance with the 72 hour rule.

Examples of diagnostic services that are covered in the 72 Hour Rule include: Lab Work Radiology Nuclear Medicine CT Scans Anesthesia Cardiology Osteopathic Services EKG EEG Unrelated Diagnostic Services are Included

MCCG has a post-submission process that identifies outpatient Medicare payments that may qualify to be inpatient. Note: Diagnostic services are not the only services included in our Systematic Charge Relocation procedures.

The distinction between "diagnostic services" and "other services" is key to understanding how the 72-Hour Rule and Medicare works. Let's look at another scenario to see the difference between the two.

One of the more confusing aspects of the 72 hour rule is that the unrelated outpatient services can be bundled with the inpatient surgery.

A return to Provider (RTP) is generated after the transmission of a claim, the claim is considered an incorrect claim and then returned to the provider. A provider may need to make claims corrections as a result of claims editing. Perform one of these actions to correct a claim error. May correct the claim via Direct Data Entry May correct on a hardcopy claim if allowed to submit paper claim May make correction of a new claim and resubmit it electronically.

There are six claim status codes that are represented in FISS by one letter. P (PROCESSED/PAID) Claim is approved for payment and is on the payment floor or claim is paid (full or partial) R (REJECTED) Claim is rejected for reasons such as Medicare eligibility issue Billing issues Duplicate to a previously submitted claim D (DENIED) Claim is denied by medical review or claim was submitted as a demand denial S (SUSPENDED) Claim is temporarily paused in FISS for processing T (RETURN TO PROVIDER) Claim is temporarily paused in FISS for processing I (INACTIVATED) Claim was inactivated from Return to Provider. Awaiting final system purge

Ambulance services are separately reimbursable only under Part B Medicare does not cover all health care services. Health care services not covered by Medicare include, but are not limited to: alternative medicine most care received outside of the United States cosmetic surgery most dental care hearing aids personal care or custodial care housekeeping services to help in the home non-medical services most non-emergency transportation, including ambulate services; preventive care transportation, except for medically necessary ambulance services most vision (eye) care

The RA is generated by Cahaba after a claim has been received and processed.

The RA explains the reimbursement decisions including the reasons for payments and adjustments of processed claims.

RA Formats Standard Paper Remittance (SPR) Electronic Remittance Advice (ERA)

The following four non-medical code sets are used extensively to provide claim and reimbursement information on the RA: Group Codes, Claim Adjustment Reason Codes Remittance Advice Remark Codes Provider-Level Adjustment Reason Codes

Pull an RA out of Sovera by check number or by batch number and batch date

Group Codes identify the financially responsible party or the general category of payment adjustment. A Group Code must always be used in conjunction with a Claim Adjustment Reason Code (CARC).

CO_Contractual Obligation - used when a contractual agreement between Medicare and the provider, or a regulatory requirement, resulted in an adjustment. When CO is used to describe an adjustment, a provider is not permitted to bill the beneficiary for the amount of that adjustment.

CR _Correction and Reversal - used for correcting a prior claim. It applies when there is a change to a previously adjudicated claim.

OA _Other Adjustment - used when no other Group Code applies to the adjustment.

PR _Patient Responsibility - represents an adjustment amount that is billed to the beneficiary or insured. This Group Code is typically used for deductible and coinsurance adjustments.

Claim Adjustment Reason Codes (CARC's) provide financial information about claim decisions . CARCs communicate an adjustment, or why a claim (or service line) was paid differently than it was billed

1 Deductible Amount 2 Coinsurance Amount 3 Co-payment Amount 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 5 The procedure code/bill type is in consistent with the place of service 40 Charges do not meet qualifications for emergent/urgent care 96 Non-covered charge(s).

Code _Informational Message M1 X-ray not taken within the past 12 months or near enough to the start of treatment M2 Not paid separately when the patient is an inpatient M3 Equipment is the same or similar to equipment already being used M4 Alert: This is the last monthly installment payment for this durable medical equipment M125 Missing/incomplete/invalid information on the period of time for which the service/supply/equipment will be needed.

Code _Informational Message N1 Alert: May appeal this decision in writing within the required time limits following receipt of this notice by following the instructions included in the contract or plan benefit documents. N24 Missing/incomplete/invalid Electronic Funds Transfer (EFT) banking information

Provider-Level Adjustment Reason Codes - Some adjustments that are made on an RA are not related to a specific claim or service. These adjustments are made at the provider level

Code __Definition __Use 50 Late Charge Used to identify Late Claim Filing Penalty or Medicare Late Cost Report Penalty 51 Interest Penalty Charge Used to identify the interest assessment for late filing 72 Authorized Return Used to identify a refund adjustment to an institutional provider 90 Early Payment Allowance Used to identify an early payment allowance

Providers are not required to give a patient an ABN for services or items explicitly excluded from Medicare coverage (items that are never covered by Medicare even if medically necessary, such as hearing aids).

If a patient does not get an ABN signed before the service or item from the provider, it is not specifically excluded from coverage, and Medicare does not pay for it, then the patient does not have to pay for it.

If the provider does give the patient an ABN that they sign before the service or item, and Medicare does not pay for it, then the patient will have to pay the provider for it

In some cases, Medicare may cover ambulance services from a patients home or a medical facility to get care for a health condition that requires the patient to be transported only by ambulance.

The following are examples of when Medicare might cover emergency ambulance transportation: Severe pain, bleeding, in shock, or unconscious. Oxygen or other skilled medical treatment during transportation. Restrained to keep a patient from hurting themselves or others.

Medicare will only cover ambulance services to the nearest appropriate medical facility that is able to give the care needed.

v If the ambulance company believes the trip is non-emergent, the patient will be asked to sign an Advance Beneficiary (ABN). If the patient signs the ABN, the patient will be responsible for the total charges if Medicare doesn't pay.

Must have a benefit letter signed by the patient

The Tax Relief and Health Care Act of 2006 made permanent the Medicare Recovery Audit Contractor (RAC) program to identify improper Medicare payments - both overpayments and underpayments-in all 50 states.

RACs are paid on a contingency fee basis, receiving a percentage of the improper overpayments and underpayments they collect from providers.

RACs may review the last three years of provider claims for the following types of services: hospital inpatient and outpatient, skilled nursing facility, physician, ambulance and laboratory, as well as durable medical equipment.

Program is now implemented in all 50 states. Two types of review: Automated (no medical record needed) Complex (medical record required)

In cases where a hospital utilization review committee determines that an inpatient admission does not meet the hospital's inpatient criteria, the hospital may change the beneficiary's status from inpatient to outpatient and submit an outpatient claim for medically necessary Medicare Part B services that were furnished to the beneficiary, provided all of the following conditions are met: The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital; The hospital has not submitted a claim to Medicare for the inpatient admission; A physician concurs with the utilization review committee's decision; and The physician's concurrence with the utilization review committee's decision is documented in the patient's medical record.

When the hospital has determined that it may submit an outpatient claim according to the conditions described above, the entire episode of care should be treated as though the inpatient admission never occurred and should be billed as an outpatient episode of care.

The most common definition is that of an employee appearing on an employer's payroll. It has also been defined as an individual receiving income that is subject to FICA taxation.

The point at which the policy limits. Either in total or in relation to a given service, have been reached, prompting a zero payment from an insure.

The Black Lung Benefits Act (BLBA) provides medical treatment for coal miners totally disabled from pneumoconiosis (black lung disease) arising from employment in or around the nation's coal mines.

The Consolidated Omnibus Budget Reconciliation Act. COBRA generally requires that group health plans sponsored by employers with 20 or more employees in the prior year offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) in certain instances where coverage under the plan would otherwise end.

The Common Working File (CWF) is the database where Medicare beneficiary eligibility information is stored.

The coordination of Benefits (COB) Contractor consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries.

A 30-month period, prompted by Medicare entitlement due to ESRD, that freezes a patient's payer order without regard to employment status.

ESRD - occurs when the kidneys are no longer able to function at a level that is necessary for day-to-day life. It usually occurs as chronic renal failure worsens to the point where kidney function is less than 10% of normal.

Government dollars extended to healthcare facilities for the treatment of a patient or patients meeting certain criteria.

- Any health plan that is offered to employees and their families by an employer.

- A form of insurance (including a self-insured plan) that provides payment based upon legal liability for injury or illness or damage to property or person.

- This type of coverage provides payments for medical treatments for bodily injury due to a covered accident up to the coverage limit.

- A term used to describe any type of insurance contract under which insured's are indemnified for losses by their own insurance company, regardless of fault in the incident generating losses.

- An extension of car insurance available in some U.S. states that covers medical expenses and, in some cases, lost wages and other damages. PIP pays regardless of who is at fault and is mandatory in some states, especially those with no-fault laws.

- A heath insurance policy that is obtained without regard to employment.

- A Medicare beneficiary is considered to be receiving recurring services if he or she is receiving identical services and treatments on an outpatient basis more than once within a billing cycle.

- Clinical laboratory diagnostic tests (or the interpretation of such tests, or both) furnished without a face to face encounter between the Medicare beneficiary and the hospital involved, in which the hospital submits a claim for such test or interpretations.

- Parties to a dispute (both parties that are being litigated before the courts, and disputes where court action has not been started) may reach an agreement as to the case, which is said to "settle" the claim.

Trauma Diagnosis - Any diagnosis that indicates an injury prompted care either in total or in part.

Veterans Affairs (DVA) - DVA medical benefits, provided to all eligible veterans, can make payment in Medicare's stead but will only do so if the service has either been approved in advance or agreed upon as a result of emergent care.

Worker's Compensation - On-the-job incidents prompt this type of diagnosis-specific payer of medical care that will always be viewed as primary to Medicare.

Method of paying for facility outpatient services

: Period of consecutive days during which medical benefits for covered services, with certain specified maximum limitations, are available to the beneficiary.

Percent of the charges after deduction of the deductible that the patient is liable for

A cash amount that must be satisfied before payment can be made under supplementary medical insurance (SMI) in each calendar year.

A classification scheme used by Medicare that clusters inpatients in categories on the basis of patients illness, disease, and medical problem.

Time when an eligible person may choose to join or leave the Original Medicare Plan or a Medicare Plus Choice plan.

are additional days that Medicare will pay for when a beneficiary is in a hospital for more than 90 days. Beneficiaries are limited to a total of 60 reserve days for their lifetime.