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Medicare. OT 232 Chapter 10 Lecture 2. Nonparticipating Providers. Decide on a claim-by-claim basis Accepted claims get 5% less for services than PAR providers Must provide surgical financial disclosures for surgeries $500+. Par vs. Nonpar , assigned vs. non-assigned.

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Medicare

Medicare

OT 232

Chapter 10

Lecture 2

OT 232 Chapter 10


Nonparticipating providers

Nonparticipating Providers

  • Decide on a claim-by-claim basis

  • Accepted claims get 5% less for services than PAR providers

  • Must provide surgical financial disclosures for surgeries $500+

OT 232 Chapter 10


Par vs nonpar assigned vs non assigned

Par vs. Nonpar, assigned vs. non-assigned

  • What is the difference between an assigned and a non-assigned claim?

  • An assigned claim means the provider will accept the Medicare allowed amount as full payment for a given service. Medicare will make payment directly to the provider. The patient is responsible for the co-insurance, which is the difference between the Medicare allowed amount and the amount Medicare paid directly to the provider. The co-insurance is usually 20% of the allowed amount.

  • For example, if Medicare approves payment to the provider for $100.00, Medicare would pay 80% ($80.00). It is the patient's responsibility to pay the difference between what Medicare allowed and what Medicare paid. In this case, the patient would pay $20.00 (20% of the Medicare allowed amount), unless the have a secondary or supplemental insurance.

  • A non-assigned claim means the provider will not accept the Medicare allowed amount as full payment. Medicare will make payment to the patient. Most services are subject to "limiting charge" regulations. The provider cannot charge the patient more than 115% of the Medicare allowed amount for services subject to limiting charge. It is the patient's responsibility to pay the full billed amount to the provider for services that are not subject to limiting charges (such as non-covered Medicare services).

  • https://www.cahabagba.com/part_b/enroll_update_your_records/enroll_part_nonpart.htm

OT 232 Chapter 10


Par vs nonpar assigned vs non assigned1

Par vs. Nonpar, assigned vs. non-assigned

  • What do the terms "assigned" and "non-assigned" mean regarding Medicare coverage?

    • An "assigned" Medicare item means the supplier accepts the Medicare-approved fee for the piece of equipment. Medicare pays the supplier 80% of the approved fee. The beneficiary pays the 20% coinsurance. A "non-assigned" item means the supplier sets the charge for the piece of equipment. The beneficiary pays the supplier. The supplier submits the claim to Medicare. If the item is covered, Medicare reimburses the beneficiary 80% of the approved fee.

OT 232 Chapter 10


Original medicare plan medicare advantage plans

Original Medicare Plan &Medicare Advantage Plans

  • Members choose between A, A & B, or C

  • Coverage is either

    • Fee-for-service (original Medicare plan)

      • Choice of participating doctor

      • Requires a deductible and coinsurance

      • MSN – Medicare Summary Notice that explains services over 30 day period

OT 232 Chapter 10


Original medicare plan medicare advantage plans cont d

Original Medicare Plan &Medicare Advantage Plans (cont’d.)

  • Managed care (Medicare Advantage, Part C)

  • Better coverage with tighter controls

  • Control features like referrals, networks, PCP

OT 232 Chapter 10


3 types of medicare advantage plans

3 Types of Medicare Advantage Plans

  • CCPs

    • Coordinated Care Plans

      • HMOs, PPOs

      • Run by major payers that offer commercial coverage; Medicare premium goes to them plus any additional

      • CMS requires plans to cover everything that the original Medicare plan does, plus additional riders

OT 232 Chapter 10


3 types of medicare advantage plans cont d

3 Types of Medicare Advantage Plans (cont’d.)

  • PFFS

    • Private Fee-for-service

    • Private insurance company

    • Medicare-approved providers

  • MSA

    • Medical Savings Account

    • High deductible, tax-exempt, fee-for-service

    • Medicare pays premium, once deductible is met, plan kicks in.

OT 232 Chapter 10


Medigap insurance

Medigap Insurance

  • Optional, private insurance

  • Often pays Part B’s deductible and additional procedures that Medicare doesn’t cover

    • If not paid by Medicare due to ‘lack of medical necessity’, Medigap is not required to pay, either

  • 10 levels of plans, but there are core benefits (page 355)

OT 232 Chapter 10


Supplemental insurance

Supplemental Insurance

  • Also used with Part B

  • Received from former employer

  • Benefits are similar to those offered in the standard health plan for current employees

  • Not regulated by CMS

OT 232 Chapter 10


Medicare billing compliance

Medicare Billing & Compliance

  • Medicare runs claims through CCI edits

    • Correct Coding Initiative

    • Checks for correct code pairings and unbundling

    • Can also scan for services billed during a global period

  • Timely filing

    • The law requires the claim to be filed no later than the end of the calendar year following the year in which the service was furnished

      • Service May 25, 2010 must be filed by December 31, 2011

      • If the service is performed in the last 3 months of the year (Oct – Dec), it counts as being part of the next year

        • Service November 16, 2010 must be filed by December 31, 2012

    • Claims late to the MAC are subject to a 10% reduction

OT 232 Chapter 10


Medicare billing compliance cont d

Medicare Billing & Compliance (cont’d.)

  • Contractors (fiscal intermediaries, carriers & MACs) audit claims on an ongoing basis to check for inappropriate billing

  • Use CERT

    • Comprehensive Error Rate Testing

  • Suspected problems result in either a

    • Probe review

    • Prepayment review

    • Postpayment review

  • ADRs (Additional Document Requests) must be responded to within 30 days

  • If things progress to a medical review, make sure compliance officer is involved; send complete documentation and keep copies of EVERYTHING

  • Overpayments must be reimbursed

  • If fraud is suspected, case will be turned over to OIG

OT 232 Chapter 10


Medicare billing compliance cont d1

Medicare Billing & Compliance (cont’d.)

  • RAC Initiative

    • Recovery Audit Contractor

    • Attempt to reduce error rate

    • RACs are paid a % of the errors they recover?!

  • Duplicate Claims

    • Medicare is NOT very lenient about duplicate claims, considers this fraudulent

    • To avoid

      • Don’t rebill if payment not received – ask!

      • Don’t bill two providers for same thing

        • Part B provider and Durable Equipment Carrier. Figure out who is primary and send it there

OT 232 Chapter 10


Medicare billing compliance cont d2

Medicare Billing & Compliance (cont’d.)

  • Split Billings

    • Can’t include noncovered services on a bill

      • Annual exam with a flu shot

    • Modifiers should be used

      • GZ, GA or GY

  • Preauthorization

    • Required for some surgical procedures

    • Determined by QIO

      • Quality Improvement Organization

      • State-based physician group paid by the gov’t. to determine appropriateness of services

      • Similar to URO used by private carriers

        • Utilization Review Organization (Ch 9)

OT 232 Chapter 10


Medicare billing compliance cont d3

Medicare Billing & Compliance (cont’d.)

  • Clinical Labs

    • Lab work can be done in physician’s office or off-site lab

    • In office

      • Easy to administer, low risk tests that don’t require special certifications, etc.

      • Modifiers required

    • Labs

      • Handle more complex testing

      • CLIA inspected and certified

        • Clinical Laboratory Improvement Amendment

      • Assigned number that will be entered on claim

OT 232 Chapter 10


Medicare billing compliance cont d4

Medicare Billing & Compliance (cont’d.)

  • ‘Incident-to’ Billing

    • If a physician’s assistant or Nurse Practitioner performs a service under the direct supervision of a physician, it may be possible to bill at the physician’s rates

  • Roster Billing

    • Medicare covers 3 vaccines

      • Flu, pneumonia and hepatitis B

    • Deductibles and coinsurance don’t apply because it saves the gov’t money for patients to get these

    • Often given to masses of people on scheduled days

      • Example – flu shot at the Fairground

    • Physician does not have to file a claim for each person, but can roster bill

      • Need basic info of patient and service provided

OT 232 Chapter 10


Preparing medicare claims misc info

Preparing Medicare ClaimsMisc info

  • Roster billing does NOT have to be electronically submitted

  • ‘Attachment’ does not mean ‘paper’. Use the electronic attachment formats and notes segments

  • HIPPA 837 has an NTE section (notes)

    • Bullets on page 361

  • By HIPPA law, paper claims cannot be processed until 29 days after receipt!

  • Claims should be sent to the carrier for the state where the service was provided, not the state where the patient lives due to GPCI

  • Different carriers can have different rules for completing the form

OT 232 Chapter 10


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