1. Chapter 12: Medicare

2. Regulated by Centers for Medicare and Medicaid Services (CMS)
Eligibility
65+ years and retired on Social Security
65+ years and retired on Railroad or Civil Service
Disabled
Child/adult with kidney disease
Kidney Donor
Medicare
3. Medicare Part A
Covers hospital services
No Charge
Usually primary payer
Medicare Part B
Covers outpatient services
Paid for by recipient
Includes physician charges
Two types of Medicare Benefits
4. Benefit period starts when the patient is admitted and ends when the patient has not been in an acute care hospital or nursing home bed for 60 consecutive days
Will pay for up to 100 days of skilled care
Must have had at least a 3 day stay at a hospital
Medicare Part A: Hospital Benefits
5. Supplemental medical insurance
Patient has to pay a premium
Medicare Part B: Medical & Preventative Care Benefits
6. Medicare Part C
Benefits are paid monthly
Covers both A & B services
Medicare Part D
Covers prescription drugs
Additional Medicare Coverage
7. Railroad Retirement Benefits
Employed Elderly Benefits
Medicare/Medicaid
Medicare/Medigap
Managed Care plans
Additional Medicare Coverage Continued
8. Risk plan
Only receive Medicare covered services from provider who are contracted member of HMO network restricted beneficiaries
Cost Plan
Receive Medicare covered services from providers outside of the HMO network unrestricted beneficiaries
Medicare Managed Care Plans
9. Quality Improvement Organization
Federal False Claims Amendment Act
Health Insurance Portability and Accountability Act
Civil Monetary Penalties Law
Stark I and II Regulations
Clinical Laboratory Improvement Amendment
Utilization and Quality Control
10. Payment Fundamentals
Participating
Non-Participating
11. Establish medical necessity
Substantiate why patient needs service
Prepayment screens
PRIOR AUTHORIZATION
12. DRGs
HCPCS
CPT
RBRVS
Medicare Reimbursement
13. Fiscal intermediaries/MACs
National Provider Identifier (NPI)
Signature on File (SOF)
Electronic submission
Cross over claims
Claim Submission
14. Explanation of Benefits (EOB)
After Claim Submission