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Day 5 Medicare Claims Processing, Appeals, Fraud & Abuse PowerPoint Presentation
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Day 5 Medicare Claims Processing, Appeals, Fraud & Abuse

Day 5 Medicare Claims Processing, Appeals, Fraud & Abuse

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Day 5 Medicare Claims Processing, Appeals, Fraud & Abuse

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  1. Day 5Medicare Claims Processing, Appeals, Fraud & Abuse

  2. Review

  3. Medicare • Never intended to pay 100% of health care costs • There are coverage gaps • For people 65+ and under 65 with a disability • 4 parts of Medicare • Part A: Hospital Insurance • Part B: Medical Insurance • Part C: Medicare Advantage Plans • Part D: Prescription Drug Coverage • Part A & B called Original Medicare

  4. Medicare Part A (Hospital Insurance) • Part A Covers: • Inpatient hospital care • Care in a skilled nursing facility (SNF) • Home health care • Hospice care • Blood

  5. Skilled Nursing Facility (SNF) Coverage • Must be a Medicare participating facility • Physician must certify that patients needs and receives daily skilled care from RN or therapist • Prior in-patient hospital stay of 3 days or more (72 hours as an admitted patient) • An overnight stay doesn’t always mean an in-patient day (can be observation day) • Break in skilled care that lasts more than 30 days will require a new 3 day hospital stay to qualify for additional SNF care • Admitted to SNF within 30 days of discharge from hospital

  6. Medicare Part B (Medical Insurance) Physicians’ Services Out-patient hospital services Durable medical equipment Prosthetics, orthotics, and supplies Ambulance Home health care (if not Part A) Blood (if not Part A)

  7. Medicare Part B: Important Terms Medicare approved amount: Fee Medicare sets for Medicare covered service Excess charges: Amount owed by beneficiary above the Medicare approved amount. In other states, there is a limit on excess charges of 15% Ban on Balanced Billing: Massachusetts has a law prohibiting excess charges by physicians Accepting Assignment: Accepting the Medicare approved amount as payment in full Participating Provider: Signing an agreement saying you agree to accept assignment for all beneficiaries in all cases (non-participating – less important in MA)

  8. Examples of Gaps in Medicare • Part A gaps: • In-patient hospital deductible • Daily co-payment for in-patient hospital days 61-90 • Daily co-payment for in-patient hospital days 91-150 • Daily co-payment for SNF days 21-100 • Part B gaps: • Annual deductible • Co-insurance (usually 20%) • First three pints of blood • Coverage outside the United States

  9. Medicare Advantage • Option for supplementing Original Medicare • Offered by a private company that contracts with Medicare to provide a beneficiary with their Part A & B benefits • The plan must offer Part D drug coverage – members who want drug coverage may onlytake drug plan offered by the Medicare Advantage plan • If enroll in a stand alone PDP, will be dis-enrolled from Part C and returned to Original Medicare • Different plan types available • HMO, HMO-POS, PPO, SNP, PFFS • Automatic disenrollment when changing MA plans

  10. Quick Reference:Pro’s of Medicare Advantage Plans • Medicare Advantage Plans tend to attract people who are not high utilizers of medical services. They also attract people who want a lower premium plan • Pro’s: • Convenience of having only one plan (drug plan can be included) • More choices available (HMO’s, PPO’s…) • Lower premiums than Medigap plans • Potential for better coordination of care (HMO’s provide this) • Additional benefits such as hearing, dental, vision and annual exams

  11. Medigap • Option for supplementing Original Medicare • Offers coverage to fill gaps in Original Medicare • Offered by private insurance companies, not the federal government • Prescription coverage NOT included; if a beneficiary wants prescription drug coverage, they must join a Medicare Prescription Drug Plan • Must call plan to dis-enroll when changing Medigap plans • Not automatic disenrollment like with Medicare Advantage • Medigap= Private companies that don’t communicate

  12. Quick Reference:Pro’s of Medigap Policies • Medigap policies tend to be bought by people with a high utilization of medical services such as doctors and hospital services. These policies are also popular amongst individuals who travel in foreign countries and who like to be able to choose which doctor they see without a referral • Pro’s: • Can see any provider that accepts Medicare (no networks) • No referrals or PCP is needed • Continuous open enrollment periods • Low to no co-pays or deductibles • Many policies offer travel coverage • All policies standard; only 2 types of policies so choosing policy is easier • ESRD 65+ can join a Medigap policy

  13. Part D • Must have Part A and/or Part B to be eligible • 2 ways to get prescription coverage: 1.Medicare Prescription Drug Plans (PDPs); also known as stand alone plans 2. Medicare Advantage (Part C) Plans with drug coverage (MA-PD’s) • Part D is voluntary, but eligible beneficiaries who do not enroll may be subject to a penalty • Must have “creditable coverage” to avoid penalty

  14. Part D • Plans can differ on many levels but must meet both pharmacy access and formulary standards set by CMS • Formulary= List of “covered drugs” in the prescription benefit • Each plan must include and cover certain drugs or certain classes of drugs • 4 Enrollment Periods • Initial: Same as Part B (7 months around birthday) • Open: Oct 15th- Dec 7th, coverage effective Jan 1st • Special: Various qualifying events • MADP: Jan 1st– Feb 14thduring which beneficiary can: • Dis-enroll from MA plan and return to original Medicare and enroll in a stand-alone Medicare Prescription Drug Plan (PDP) • Dis-enroll from MA plan without drug coverage and enroll in a PDP

  15. Extra Help • Federal assistance program to help low-income and low-asset Medicare beneficiaries with costs related to Medicare Part D • Extra Help subsidizes: • Premiums • Deductibles • Copayments • Coverage Gap “Donut Hole” • Late Enrollment Penalty • Does NOT subsidize non-formulary or excluded medications • Apply through Social Security Administration

  16. Extra Help • Full Extra Help • 135% of the Federal Poverty Level (FPL) and asset limits • Full premium assistance with no deductible • Low, capped co-payments. Could be $0 for some generics at any level • Partial Extra Help • 150% of the FPL and asset limits • Reduced premiums (sliding scale – between 25% -75% assistance dependent upon income) • Reduced deductible and 15% copayments

  17. Prescription Advantage Massachusetts’ State Pharmacy Assistance Program (SPAP) Provides secondary coverage for those with Medicare or other “creditable” drug coverage (i.e. retiree plan) Provides primary prescription coverage for those who don’t qualify for Medicare Benefits are based on a sliding income scale only– no asset limit! Level of assistance provided is determined by gross income Different income limits for under 65 and 65 and over Members are provided a SEP (one extra time each year outside of open enrollment to enroll or switch plans)

  18. Medicare Claims Processing, Appeals, Fraud & Abuse

  19. Claims Processing • Medicare processes over 3 million claims daily for over 39 million beneficiaries • Providers required to process claims directly to Medicare • Medicare pays for services under the Prospective Payment System where providers are paid a fixed amount based on payment categories • Medicare Administrative Contractors (MAC’s) • Private companies that contract with Medicare to process Part A & B claims, investigate fraud & abuse, mail Medicare Summary Notices, provide beneficiary customary services

  20. Medicare Summary Notice (MSN) • Medicare beneficiaries will receive a Medicare Summary Notice (MSN) on a quarterly basis • This is a statement, not a bill • The MSN details: • Part A and Part B inpatient and outpatient claims processed during the period • Dates of service • Amount billed and paid to the provider and other vital information • Beneficiaries shouldn’t pay providers until MSN is received to match provider bill with beneficiary’s record

  21. Medicare Approved Amount Medicare decides amount is reasonable for a particular covered service Adjusted geographically These are paid after the A & B deductibles are met Medicare Part B pays 80% of the Medicare approved amount for most services after the beneficiary has met the annual deductible

  22. Non-participating Providers • Providers can opt to accept assignment or not accept on a case-by-case decision • Medicare only pays for durable medical equipment (DME) purchased from a participating provider • If provider does not accept assignment: • Provider is not accepting the Medicare approved amount • Beneficiary may be required to pay up front and file a claim with Medicare or other insurers • Beneficiary must pay the difference between retail price and Medicare approved amount • Provider must still bill Medicare

  23. Medicare and MassHealth Doctors and most providers must accept assignment for beneficiaries who are on MassHealth AND Medicare

  24. Limiting Charge Non-participating doctors can charge up to 115% of the Medicare approved amount Does NOT apply to Durable Medical Equipment DOES NOT APPLY IN MASSACHUSETTS

  25. Massachusetts Ban On Balance Billing Law • Prohibits doctors licensed in Massachusetts from billing Medicare beneficiaries for more than the Medicare approved amount • Applies only to services provided in Massachusetts • Massachusetts doctors who are “non-participating providers” and work in other states may charge a patient up to 15% above the Medicare approved amount • These are called legitimate excess charges • Some other states that limit Medicare charges include Connecticut, Rhode Island, Vermont and New York

  26. Billing Medicare Federal Law mandates all providers who furnish services and products to Medicare beneficiaries submit claims to Medicare Also applies to beneficiaries who pay up front

  27. Crossover Billing Participating providers, Medicare contractors, Medigap insurers and most other private insurers participate in crossover billing for Medicare beneficiaries who assign both Medicare and Medigap payments to their providers After the Medicare portion of the claim has been processed, Medicare forwards the balance of the claim to the Medigap insurer or other insurer for payment of covered amounts For crossover to work, the Medicare beneficiary must provide complete and accurate information to all their Medicare providers about their other health insurance coverage, including their Medigap policy

  28. Medicare as Secondary Payer • Medicare is the primary payer for most beneficiaries with Medicare supplement insurance policies • In general, Medicare is the secondary payer for Medicare covered services if the beneficiary is also covered by any of the following: • Motor vehicle or liability insurance • Employer group insurance • Public Health Service • Indian Health Service • Workers’ Compensation • Black Lung Program

  29. Medicare Patient Rights • The right to receive easy-to-understand information about Medicare including info on costs, payments, how to file an appeal • The right to file appeals and grievances • The right to know all treatment options from the health care provider in language that is understandable and clear to the beneficiary • The right to emergency care without prior approval anywhere in the United States • The right to have personal information that Medicare collects kept private

  30. Medicare Fraud & Abuse • Fraud • The intentional deception or misrepresentation that an individual makes knowing that it could result in an unauthorized benefit • Abuse • The unintentional practice or procedure inconsistent with sound medical, business or fiscal practice resulting in a provider receiving payment that fail to meet recognized standards of care or incur unnecessary costs

  31. Utilization Review Committee (URC) • The URC continually reviews patients’ stays in hospitals and skilled nursing facilities • URC works within facilities and is comprised of doctors or professionals not related to the patients involved • Each admitted person’s doctor must satisfy the URC that the patient meets the admission criteria and continues to need an acute hospital level of care • A URC has the authority to terminate Medicare’s obligation to pay for medical services in a hospital or skilled nursing facility • It is the URC that determines that it’s time to be discharged • If a patient disagrees, s/he may appeal

  32. Hospital/Skilled Nursing Facility Discharge Patient Rights • Hospitals are required to deliver the Important Message from Medicare (IM), to all Medicare beneficiaries (Original Medicare & MA beneficiaries) who are hospital inpatients which informs them of their hospital discharge appeal rights • To appeal a proposed discharge, beneficiary should call MassPROand request an immediate review of the notice • MassPRO is the Quality Improvement Organization [QIO]; an organization of doctors and nurses who contract with Medicare to review hospital discharge decisions • The MassPro helpline is available 24 hours a day, 7 days a week, including holidays

  33. Where to go for Help: Appeals & Grievances • MAP (Massachusetts Medicare Advocacy Project) • Provides free advice and legal representation for Massachusetts Medicare beneficiaries • (866) 778-0939 or (800) 323-3205 • MassPro (Massachusetts Peer Review Organization) • Group of practicing doctors and other health care professionals paid by the federal government to review and monitor quality of care given to Medicare beneficiaries • Processes quality of care complaints and grievances and some hospital appeals • (800) 252-5533; www.masspro.org

  34. Quiz • While driving to work Josephine has a minor traffic accident. As a precautionshe was transported to the hospital in an ambulance and was examined by a physician in the ER. Josephine gave the emergency room clerk her Medicare and Medigapinsurance information. Several weeks later Josephine received a denial from Medicare for the services. Who pays first? • Insurance b)Health Plan c) Medicare d) Employer Health Plan

  35. Quiz, cont. Harriet has been in the hospital for 4 days recovering from gall bladder surgery. The hospital staff has informed her that she is being discharged the following day. Harriet does not feel strong enough to return home and wants to appeal this discharge. To whom should she direct her appeal? a) Medicare Advocacy Project b) Medicare Part B c) Mass PRO d) Surgeon General What are the guidelines for an Expedited Appeal? Mary Jones bas been receiving home health services for the past 6 weeks. She calls you because the home health agency informed her today that she will be discharged from receiving these services next week. Mary feels she still needs physical therapy. How would you help her?

  36. Case Study 1:Mr. Felix DeKatt • Felix has diabetes and has been seeing a podiatrist for the past three months for foot care. Recently Felix changed doctors and was asked to pay $75 for the office visit. Felix was sure that Medicare paid for these services since he had never received a bill from his previous podiatrist. When Felix questioned the billing clerk in the doctor’s office, he was told that Medicare does not cover routine foot care. • How would you help him?

  37. Case Study 2:Cal Asthenik • Cal was having a hard time walking. He received a call from a company that sells wheelchairs. He ordered a wheelchair after the salesperson assured him that Medicare would reimburse him for the expense. He was surprised to find that Medicare would not pay for it. What would you tell him about the procedure for getting a wheelchair under Medicare? • How would you help him with this situation?

  38. Case Study 3:Fran Tikk Fran is 71 and on a federal employee group retiree plan with Blue Cross/Blue Shield (BCBS) for which she is paying a premium of over $150/mth. She has had many health problems recently, and her plan doesn’t provide full coverage. When she turned 65 in 2005, she called Social Security (SS) to see about enrolling in Medicare. She was told she was not eligible for Medicare because she hadn’t worked under SS. In 2007 a rep at her BCBS plan told her she would be eligible for Medicare under her ex-spouse who had worked under SS. (They had been married for more than 10 years.) The SS worker confirmed that she was eligible under her former spouse but would face a penalty for not signing up back in 2005. Fran refused Medicare at that point because she could not afford it with the penalty. (Goss income less than $1000/month, with few savings). Fran was told by the rep at BCBS that if she could get Medicare A&B, her BCBS would act as a supplement providing full coverage at a lower cost. She could drop down to a plan that would cost far less than what she is currently paying.

  39. Case Study 4:Jack R. Abbot • Mr Abbot is retired and having problems with his insurance covering his medical bills. He keeps getting denial notices for many of the services he receives. He wants to meet with you to get some help with resolving the situation. • What information would you ask Mr. Abbot to bring to your meeting? • How would you help him?

  40. Case Study 5:Mr. Perry Scope • Mr. Scope fell and broke his hip. Since his discharge from the hospital he has been receiving physical therapy services in his home. He was told by his physical therapist, however, that the therapy will end next week. Mr. Scope thinks that he needs more therapy. • How would you help him?

  41. Case Study 6:Barbie Que • Barbie calls you at the SHINE office. She tells you she has been covered under Blue Cross/Blue Shield’s Medex Gold plan because she takes a lot of medications. She is very satisfied with the Gold plan but is finding it difficult to pay the premium on top of the expenses she has maintaining her home. Barbie looked into the program through Social Security that helps pay for prescription costs, but tells you her monthly income of $1,725 and assets of $40,000 make her ineligible. • How would you help her?

  42. Case Study 7:Al Falfa • Al meets with you at the SHINE office. He will be 65 next month and is retiring. He has just returned from Social Security and will receive Medicare A and B. His neighbor has a Medigap Supplement 1 plan, so he also signed up effective on the first of next month when his Medicare begins. He has three prescriptions: one is a brand, Advair, and the other two are generics. He has heard negative things about Part D, so he tells you he may just pay for his prescriptions out of pocket. His only income will be $11,900/year from Social Security, and he currently has $8000 in the bank. • How would you help him?

  43. Case Study 8:Jen Teal • Jen joined a Part D plan last year but wants to find out if there is a better plan she can join this year. She takes a few expensive brands which she paid for in full during the donut hole at a cost of several hundred per month. A friend told her she should have signed up for the plan that covers brands during the donut hole, so she wants to know if that’s what she should do this year. Her only income is SS of $1,450 per month, she has assets that make her ineligible for benefit programs. She lives in her own home and wants to stay there for as long as she can afford to. Although her assets prevent her from getting any assistance, she uses her assets to help with her prescription costs and to maintain her home. • How would you help her?