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Title: Day 5 Medicare Claims Processing, Appeals, Fraud


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 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

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
  • 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

10
Quick 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

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,
    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

12
Quick 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

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-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

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 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

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 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)

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 (MACs)
  • 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 shouldnt pay providers until MSN
    is received to match provider bill with
    beneficiarys 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 (participating
    and non-participating) 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
  • 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)

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 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

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 MassPRO and 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
Discharge Patient Rights, cont.
  • Once Masspro receives the request, they will
    review the appeal within 24 hours of receiving
    the medical record
  • Masspro 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
    Mass-Pro within the required time-frame, the
    hospital may NOT discharge the beneficiary until
    Mass-Pro has completed its review
  • Patient liability begins the day following the
    Masspro decision

34
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

35
Review
  • 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?

36
Case Study 1Mr. 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 doctors office, he was told that
    Medicare does not cover routine foot care.
  • How would you help him?

37
Case Study 2Cal 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 3Fran 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 doesnt 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 hadnt 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 AB, 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 4Jack 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 5Mr. 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 6Barbie Que
  • Barbie calls you at the SHINE office. She tells
    you she has been covered under Blue Cross/Blue
    Shields 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 7Al 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 8Jen 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 thats 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?

44
Quiz
  • While driving to work Josephine has a minor
    traffic accident. As a precaution she 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
    Medigap insurance 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

45
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?
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