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CHAA Examination Preparation. Pre-Encounter - Session IV Pages 52-61 University of Mississippi Medical Center. What to Expect…. This module covers various aspects of Patient Access knowledge found in pages 52-61 of the Pre-Encounter section of the 2010 CHAA Study Guide.

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Chaa examination preparation

CHAA Examination Preparation

Pre-Encounter - Session IV

Pages 52-61

University of Mississippi Medical Center

What to expect

What to Expect…

  • This module covers various aspects of Patient Access knowledge found in pages 52-61 of the Pre-Encounter section of the 2010 CHAA Study Guide.

  • A quiz at the end will measure your understanding of the content covered.

Centers for medicare and medicaid services cms

Centers for Medicare and Medicaid Services (CMS)

  • CMS is a government agency created to administer the largest FEDERAL health programs. It also works with CHIP for uninsured children.

  • The overall goal of CMS is to assure health security for its beneficiaries.

Centers for medicare and medicaid services cms1

Centers for Medicare and Medicaid Services (CMS)

  • CMS looks out for their beneficiaries by performing QUALITY ASSESSMENT and PERFORMANCE IMPROVEMENT programs for CMS accredited hospitals.

  • They promote Health Standards and a high quality of care by assigning PEER REVIEW ORGANIZATIONS (PROs) to monitor and improve healthcare in each state.

Peer review organizations pros

Peer Review Organizations (PROs)

PROs have two main functions in serving CMS beneficiaries:

1.) They conduct COOPERATIVE QUALITY IMPROVEMENT PROJECTS to increase the quality of care by examining and improving health-care delivery processes.

2.) They provide BENEFICIARY PROTECTION AND EDUCATION thorough mandatory case review of beneficiary complaints and outreach activities.

Efficiency and fiscal integrity

Efficiency and Fiscal Integrity


  • The Centers for Medicare Services (CMS) LEADS the HEALTHCARE INDUSTRY in the use of ELECTRONIC TECHNOLOGY for all phases of claims processing which REDUCE ADMINISTRATIVE COSTS.

    Fiscal Integrity:

  • In 1992, CMS began paying physicians according to a NATIONAL FEE SCHEDULE based on the work and overhead costs associated with each medical service.

Drg apg c


In an effort to limit the increasing costs of healthcare, CMS proposed a “Prospective Payment System” which lists the amounts CMS will reimburse for each procedure.

  • DIAGNOSIS RELATED GROUP (DRG) – is the fee schedule for all INPATIENT services.

  • AMBULATORY PAYMENT GROUP (APG) – is the fee schedule for OUTPATIENT services. It is also known as the Ambulatory Payment Classification System (APCs).

Cms fraud and abuse

CMS Fraud and Abuse

  • The Department of Justice (DOJ), Office of Inspector General (OIG), and other federal and state agencies work with CMS to prevent fraud and abuse.

  • Funding to combat fraud and abuse is provided through HIPAA.

Medicare rules

Medicare Rules

  • Unintentional failure to follow CMS rules and guidelines carries severe FINES and PENALTIES.

  • In cases of INTENTIONAL FRAUD, Medicare will not only pursue the hospital, but the INDIVIDUAL EMPLOYEE as well.

Cms fiscal intermediaries

CMS Fiscal Intermediaries

  • Fiscal Intermediary is a fancy word for a “financial go-between.”

  • These private agencies are contracted by CMS to perform bill and claims processing and pay benefits on behalf of Medicare.

  • Basically, CMS outsources these services to outside companies.

Fiscal intermediary responsibilities

Fiscal Intermediary Responsibilities

Fiscal Intermediaries are also responsible for:

  • Determining whether services are MEDICALLY NECESSARY and if they constitute an APPROPRIATE LEVEL OF CARE.

  • Deterring and detecting MEDICARE FRAUD.

  • Auditing provider cost reports to ensure that Medicare PAYS THE APPROPRIATE AMOUNT when the BENEFICIARY HAS OTHER HEALTH INSURANCE.

Medicare eligibility requirements

Medicare Eligibility Requirements:

Medicare is a federal health insurance program for:

  • Patients age 65 and OLDER



Medicare card

Medicare Card

A patient’s Medicare card will identify:

  • If the patient has Part A and/or Part B

  • When those benefits became effective

  • The Medicare Claim number which is usually the patient or spouse’s social security number with a letter/number prefix.

    Medicare Beneficiaries are automatically eligible and must apply 3 months before their 65th birthday.

Medicare part a

Medicare Part A

This is Hospital Insurance and helps pay for:





Medicare part b

Medicare Part B

This helps pay for:

  • Doctor Services

  • Outpatient Hospital Services

  • Medical Equipment and Supplies

  • Emergency Room Visits

  • Ambulance Service

Medicare part c

Medicare Part C

This is known also as the “Medicare Advantage Plan.”

  • In this plan, the beneficiary pays extra for a PRIVATE INSURANCE COMPANY to manage their Medicare coverage.

  • It is usually in the form of an HMO or PPO.

  • It usually results in more healthcare options.

Medicare part d

Medicare Part D

This helps cover PRESCRIPTION DRUGS and MAY lower prescription drug costs.

Medicare miscellaneous rules

Medicare Miscellaneous Rules

  • BENEFIT PERIOD – begins on the FIRST DAY of services in an inpatient or SNF facility and ends 60 days after discharge IF that 60 days ISN’T INTERRUPTED by SKILLED CARE in ANOTHER FACILITY.

  • Beneficiaries can have an UNLIMITED number of benefit periods but must pay the inpatient deductible for each period.

  • 72 HOUR/3 DAY RULE – states that preadmission testing or diagnostic services provided by the admitting hospital within three days of admission BE INCLUDED IN THE INPATIENT PAYMENT.

Medicare miscellaneous rules1

Medicare Miscellaneous Rules

  • LIFETIME RESERVE DAYS – Medicare pays for 60 days of hospitalization in instances where the patient is an inpatient for MORE THAN 90 DAYS. They can be used ONLY ONCE IN A LIFETIME.

  • Except for certain limited cases in Canada and Mexico, Medicare does not pay for treatment outside the United States.

  • Medicare (Part A) pays for skilled nursing home care for REHABILITATION SERVICES ONLY. It doesn’t pay for general custodial services.

Important message from medicare form

“Important Message From Medicare” Form

This form is given to ALL MEDICARE BENEFICIARIES in INPATIENT HOSPITALS and it explains:

  • Their rights to needed care and any follow-up care after discharge.

  • It provides a number to a Peer Review Organization (PRO) to call if they feel they are being discharged too early.

  • Beneficiaries may remain in the hospital without being charged while their case is being reviewed.

Hospice care

Hospice Care

  • This assists with care for terminally ill beneficiaries who select the hospice care benefit.

  • There are no deductibles but beneficiaries pay limited costs for drugs and respite care.

Advanced beneficiary notice abn

Advanced BeneficiaryNotice (ABN)

The ABN should be given to the beneficiary to sign if:

  • Medicare MAY NOT consider the service to be provided as MEDICALLY NECESSARY

    - BECAUSE -

  • If not, there is a good chance Medicare WILL NOT PAY for the service and THE PATIENT WILL BE BILLED FOR IT.

Advanced beneficiary notice abn cont d

Advanced Beneficiary Notice (ABN) Cont’d

  • If the ABN has NOT BEEN SIGNED BEFORE SERVICE IS provided and Medicare doesn’t pay for it, THE PATIENT CANNOT BE HELD RESPONSIBLE for paying the bill.

  • If the ABN was signed before the service, the patient may be billed.

  • Many Fiscal Intermediaries are now using SOFTWARE that compares the diagnosis to the service thereby determining MEDICAL NECESSITY.

Medicare secondary payer questionnaire mspq

Medicare Secondary Payer Questionnaire (MSPQ)

  • The MSPQ is necessary because some Medicare beneficiaries have other insurance (not including Medigap) that must pay before Medicare.

  • The MSPQ should be completed on ALL MEDICARE PATIENTS each time a service is provided to assure that appropriate billing guidelines are followed.

Medicare is secondary payer if

Medicare is Secondary Payer if:

  • Patient is 65 or older and covered by group health insurance with an employer with 20 OR MORE EMPLOYEES for whom they or their spouse is currently working.

  • Patient is under 65 and DISABLED, they or any member of their family is currently working for an employer with 100 OR MORE EMPLOYEES.

  • Patient has Medicare because of permanent kidney failure (ESRD).

  • Patient has an illness or injury that is covered under workers’ compensation, the federal black lung program, no-fault insurance, or any liability insurance.

Medicare miscellaneous rules2

Medicare MiscellaneousRules

  • When a beneficiary cannot recall his/her retirement date, but knows it occurred prior to their entitlement date, you can use their Medicare Entitlement Date as the retirement date.

  • For recurring visits where patient has several recurring visits for the same service(such as physical therapy), all charges are entered into one account.

  • For recurring visits, you are required to verify MSPQ information every 90 days.

How medicare pays

How Medicare Pays

  • Medicare pays fixed amounts to hospitals according to patient’s diagnosis based on the DIAGNOSIS RELATED GROUPING (DRG – INPATIENT) and AMBULATORY PAYMENT CLASSIFICATION (APC – OUTPATIENT).

  • Hospitals can receive a higher payment or “add-on” for services if it serves a great percentage of low-income patients or is an approved teaching hospital.

Medicare supplemental insurance

Medicare Supplemental Insurance

These are Private Insurance plans that pay some or all of healthcare costs not covered by Medicare:

  • Employee Coverage - from a CURRENT employer or union

  • Retiree Coverage - from a FORMER employer or union

  • Medigap Coverage – from a private company or group designed to help pay cost-sharing amounts and uncovered services

Medicare managed care

Medicare Managed Care

  • In most managed care plans, patients can only go to certain doctors and hospitals that agree to treat members of the plan.

  • Doctors can join or leave the plan at any time.

  • Patients need a referral to see a specialist.

  • Some managed care plans offer a Point-of-Service option which allows patients to go to other doctors and hospitals who aren’t a part of the plan.

  • Managed Care Plans usually cost more, but often provide more options for beneficiaries.

Private fee for service process

Private Fee-for-Service Process

  • With this plan, the private company, rather than Medicare, decides how much it and patients pay for outlined services.

  • Patients can go to any provider that accepts the terms of the plan’s payment.



  • Medicaid was established by federal legislation in 1965 to provide health care coverage for categories of low-income people.

  • States have the freedom to design their program and decide:

    • Eligibility standards

    • What benefits and services to cover

    • What payment rates to charge

Medicaid qualifications

Medicaid Qualifications

  • Certain low income families with children

  • Aged, blind, or disabled people on Supplemental Security Income

  • Certain low income pregnant women and children

  • Certain people who would not otherwise be eligible but qualify as the result of catastrophic medical expenses

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