Title: Day 5 Medicare Claims Processing, Appeals, Fraud
1Day 5Medicare Claims Processing, Appeals, Fraud
Abuse
2Review
3Medicare
- 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
4Medicare Part A (Hospital Insurance)
- Part A Covers
- Inpatient hospital care
- Care in a skilled nursing facility (SNF)
- Home health care
- Hospice care
- Blood
5Skilled 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 doesnt 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
6Medicare 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)
7Medicare 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)
8Examples 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
9Medicare Advantage
- Alternative option to 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 only take 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
10Quick ReferencePros 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 - Pros
- Convenience of having only one plan (drug plan
can be included) - More choices available (HMOs, PPOs)
- Lower premiums than Medigap plans
- Potential for better coordination of care (HMOs
provide this) - Additional benefits such as hearing, dental,
vision and annual exams
11Medigap
- 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,
she/he 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 dont communicate
12Quick ReferencePros 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 - Pros
- 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
13Part 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-PDs) - Part D is voluntary, but eligible beneficiaries
who do not enroll may be subject to a penalty - Must have creditable coverage to avoid penalty
14Part 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 14th during 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
15Extra 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
16Extra 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
17Prescription 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 dont 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)
18Medicare Claims Processing, Appeals, Fraud Abuse
19Claims 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 (MACs)
- Private companies that contract with Medicare to
process Part A B claims, investigate fraud
abuse, mail Medicare Summary Notices, provide
beneficiary customary services
20Medicare 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 shouldnt pay providers until MSN
is received to match provider bill with
beneficiarys record
21Medicare 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
22Non-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
23Medicare and MassHealth
- Doctors and most providers must accept assignment
for beneficiaries who are on MassHealth AND
Medicare
24Limiting 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
25Massachusetts 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
26Billing Medicare
- Federal Law mandates all providers (participating
and non-participating) who furnish services and
products to Medicare beneficiaries submit claims
to Medicare - Also applies to beneficiaries who pay up front
27Crossover 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
28Medicare 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
29Medicare 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
30Medicare Appeals
- Beneficiaries have the right to a fair and
efficient process for appealing decisions about
health care payment or services - No matter what kind of Medicare plan,
beneficiaries have and should be appraised of and
encouraged to use their appeal rights
31Appealable Events
- Medicare denies a request for a health care
service, supply, or prescription - Medicare denies payment for health care that the
beneficiary has already received - Medicare stops covering services that the
beneficiary is already receiving - Medicare pays a different amount than the
beneficiary believes it should
32Medicare Equitable Relief
- Procedure that can be used to address premium
penalties imposed and/or delayed coverage due to
late enrollment
33Keep In Mind
- Medicare covers services that are reasonable and
necessary - When in doubt, a beneficiary should protect their
rights by appealing - An appeal can always be withdrawn later without
any penalty - It is always important to read notices carefully,
follow instructions, and watch for deadlines - Physician support is key
34Medicare 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 - Where to report suspected fraud
- 1-800-MEDICARE or the Inspector Generals Hotline
(800-447-8477) - Medicaid fraud Office of the Attorney General,
Medicaid Fraud Control Unit (617-727-2200
x3404) - Part C or Part D fraud SafeGuard Services
(877-772-3379) -
35Utilization 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 persons 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 Medicares
obligation to pay for medical services in a
hospital or skilled nursing facility - It is the URC that determines that its time to
be discharged - If a patient disagrees, s/he may appeal
36Hospital/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 Livanta and request an immediate
review of the notice - Livanta is the Beneficiary and Family Centered
Care Quality Improvement Organization BFCC-QIO
an organization of doctors and nurses who
contract with Medicare to review hospital
discharge decisions
37Discharge Patient Rights, cont.
- Once Livanta receives the request, they will
review the appeal within 24 hours of receiving
the medical record - Livanta informs the beneficiary and the
healthcare provider of the decision first by
phone, then by letter and also provides
information about additional appeal rights - If the beneficiary believes they are being made
to leave the hospital too soon and they call
Livanta within the required time-frame, the
hospital may NOT discharge the beneficiary until
Livanta has completed its review - Patient liability begins the day following the
Livanta decision
38Where 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
- Livanta (Beneficiary and Family Centered Care
Quality Improvement Organization (BFCC-QIO) - 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 - (866) 815-5440 www.bfccqioarea1.com
39Review
- What is a Medicare Summary Notice?
- Providers can opt to accept/not accept assignment
on a case-by-case decision - True False
- What are some Medicare Patient Rights?
- What is the difference between Medicare fraud and
Medicare abuse? - Who provides free advice and legal representation
for Massachusetts Medicare beneficiaries?