Transcript Medicare Resident & New Physician Training

1.5-HOUR
INTRODUCTION
TO MEDICARE
POWERPOINT
PRESENTATION
Medicare
Resident & New
Physician Training
Medicare
Resident & New
Physician Training
Medicare
Resident & New
Physician Training
Medicare
Resident & New
Physician Training
Medicare
Resident & New
Physician Training
Medicare
Resident & New
Physician Training
Pre-Assessment

Please complete the PreAssessment now
 The purpose of the PreAssessment is to
determine your knowledge
of the Medicare Program
prior to today's session
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Learning Objectives
Identify Medicare’s three parts
Determine who are Medicare insured beneficiaries
List the two identifying numbers physicians are assigned upon acceptance into
the Medicare Program
Recognize the benefits of becoming a Medicare participating physician
Identify two types of claims or requests for Medicare payment
Describe the benefits of Electronic Data Interchange
Determine when Medicare is considered the secondary payer
Determine when services or supplies are considered medically necessary
List the conditions that must be met under the “Incident to” Provision
Describe what medical documentation facilitates
Identify the three key components in selecting the levels of Evaluation and
Management services
Learning Objectives
Identify the benefits of the medical review process
Identify the four types of corrective action that Medicare may take
List the five levels of the appeals process
Determine when a service or item requires an Advance Beneficiary
Notice
Describe measures that can help protect a physician’s practice
Identify a tool that ensures compliance with Medicare requirements
Identify five examples of fraud
Identify five examples of abuse
Identify four Anti-Fraud Provisions
Identify three provisions of the Health Insurance Portability and
Accountability Act
The Medicare Program

Provides medical coverage to 95 percent of the
nation’s aged population
 3 parts - A, B, and C or Medicare + Choice
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Medicare Part A
Hospital Insurance

Provides reimbursement for
– Inpatient hospital care
– Inpatient care in a Skilled Nursing Facility
following covered hospital stay
– Some home healthcare
– Hospice care
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Medicare Part B
Medical Insurance
 Helps pay for
– Medically necessary services provided by a
physician
– Home healthcare
– Ambulance services
– Clinical laboratory and diagnostic services
– Surgical supplies
– Durable medical equipment and supplies
– Services by practitioners with limited licensing
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Part C or Medicare + Choice

Part C or Medicare + Choice plans
– Health Maintenance Organization
– Point of Service Option
– Provider Sponsored Organization
– Preferred Provider Organization
– Private Fee-For-Service Plan
– Religious Fraternal Benefit Society Plan
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Medicare Eligibility

3 groups of insured beneficiaries
– Aged Insured - at least 65 years old
– Disabled Insured - entitled after receiving
disability for 24 months
– End-Stage Renal Disease Insured - receive
regular dialysis treatments or kidney transplant
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Medicare Physician
Doctor of medicine or osteopathy
Doctor of dental surgery or dental medicine
Chiropractor
Doctor of podiatry or surgical chiropody
Doctor of optometry
Legally authorized to practice by state in
which function is performed
Physician Enrollment

Include with Form CMS-855
– State medical license
– Occupational/business license
– Certificate of Use
– Form CMS-460 – Participating Physician or
Supplier Agreement
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Provider Identification Number
Unique Physician/Practitioner Number

Provider Identification
Number (PIN)
– Provider billing number
– Identifies who provided
services
– Required on all claims

Unique Physician/
Practitioner Number
(UPIN)
– Identifies ordering or
referring physician
– Referring physician
requests an item/service
or ordering physician
orders nonphysician
services
– Permanent number used
in any state
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Participating Physician
A participating physician
agrees to accept
assignment for all covered services for all patients
Physician
Fee Schedule based on 3 Resource-Based
Relative Value Units associated with time, intensity,
and technical skill required and practice’s overhead
expenses
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Participating Physician

Physician Fee Schedule information
www.cms.hhs.gov/physicians/mpfsapp/step0.asp

Physicians must collect
– Unmet deductibles
– Routine fees for excluded services
– Applicable coinsurance amounts
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Benefits of Participation

Access to beneficiary eligibility files
 5 percent higher Physician Fee Schedule
allowances
 Automatic Medigap crossover
 Inclusion in MEDPAR directory
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Nonparticipating Physicians

May accept assignment on case-by-case basis
 Held to limiting charge for nonassigned claims
 Must file all potentially reimbursable claims
 May collect up to limiting charge
 5 percent lower Physician Fee Schedule
allowances
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Physician Reimbursement
Health
Professional Shortage Area
Additional reimbursement available for services
rendered to beneficiaries in rural areas
Limiting
Charge
Maximum amount a nonparticipating physician may
legally charge a Medicare patient for covered services on
nonassigned claims
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Types of Medicare Claims

Assigned Claims
– Participating physician must accept assignment
– Nonparticipating physician held to assignment
for that claim only
– Physician reimbursed directly

Nonassigned Claims
– Part B claims - beneficiary reimbursed directly
– Beneficiaries responsible for entire bill, up to
limiting charge for most services
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Benefits of Electronic
Data Interchange
Claims paid on 14th day compared to 27th day
after submission for paper claims
 Certificates of Medical Necessity
 Eligibility, deductible, and enrollment
information
 Paid and/or denied claims information

 Pending

claims status
Electronic Funds Transfer
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Medicare Secondary Payer

When other health insurance or coverage is
required to pay primary health benefits
 All healthcare providers must determine if
Medicare is secondary payer
 Medicare Secondary Payer Questionnaire
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Benefit Plans
Primary to Medicare

Group Health Plans
 Workers’ Compensation
 Federal Black Lung Program
 No-Fault or Liability Insurance
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Medically Reasonable
and Necessary Services

Proper and needed for diagnosis and treatment of
patient’s medical condition
 Provided for diagnosis, direct care, and treatment of
patient’s medical condition
 Meet standards of good medical practice
 Not mainly for convenience of patient or physician
Every service billed must indicate specific sign,
symptom, or patient complain necessitating the service
"Incident to" Provision

Services rendered by physicians or auxiliary
personnel under physician’s direct supervision
– In office setting, physician must be in office
suite and available for assistance and direction
– Furnished as integral, although incidental part of
physician’s professional services
– Must have valid employment arrangement
between physician/clinic and employee
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Covered Preventive Services

Bone mass measurements
 Diabetes self-management services
 Pneumococcal, influenza, and hepatitis vaccinations
 Screening:
–
–
–
–
–
–
Mammography
Pap tests
Pelvic examinations
Colorectal cancer
Prostate cancer
Glaucoma services
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Services Medicare
Does Not Pay For
 Excluded
 Not
reasonable and necessary
 Bundled
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Medical Record
Documentation Facilitates

Ability to evaluate and plan treatment and
monitor health over time
 Communication and continuity of care
 Accurate and timely claims review and payment
 Utilization review and quality of care
evaluations
 Data collection
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Seven General Principles
of Documentation
1. Medical record should be complete and legible
2. Each encounter should include
 Reason for encounter, relevant history,
physical examination findings, and prior test
results
 Assessment, clinical impression, or diagnosis
 Plan for care
 Date and legible identify of observer
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Seven General Principles
of Documentation
3. Rationale for ordering diagnostic tests
4. Diagnoses accessible to treating/consulting
physicians
5. Identify health risk factors
6. Document patient's progress, response to and
changes in treatment, and revision of diagnosis
7. CPT and ICD-9-CM codes on health claim
form supported in medical record
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Evaluation and
Management Services

7 components that define E/M services
History
Examination
Medical Decision Making
Counseling
Coordination of Care
Nature of Presenting Problem
Time
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New Patient Visit Requires That
All 3 Key Components Are Met
Procedure Code
History
History
Examination
Examination
Medical
Decision
Medical Decision
Making
Making
99201
Problem Focused
History
Problem Focused
Examination
Straightforward
99202
Expanded Problem
Focused History
Expanded Problem
Focused
Examination
Straightforward
99203
Detailed History
Detailed
Examination
Low Complexity
99204
Comprehensive
History
Comprehensive
Examination
Moderate
Complexity
99205
Comprehensive
History
Comprehensive
Examination
High Complexity
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Key Components
Selecting Levels of E/M Services
History
–
Chief complaint
– Review of systems
– Past, family, and/or social history
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Key Components
Selecting Levels of E/M Services
Examination
–
Problem focused
– Expanded problem focused
– Detailed
– Comprehensive

May choose
–
General Multi-System
– Single Organ System
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Documentation
of Examination

Any physician can perform General MultiSystem and Single Organ Examinations
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Key Components
Selecting Levels of E/M Services
Medical Decision Making
–
Straightforward
– Low complexity
– Moderate complexity
– High complexity
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Medical Decision Making
2 of 3 Elements Must
Be Met or Exceeded
Number of
Number
of
Diagnoses/
Diagnoses/
Management
Management
Options
Options
Amount
and/or
Amount and/or
Complexity of
Complexity
of
Data
Data
Risk
of
Type of Medical
Risk of
Complication
Complication
Decision Making
and/or Morbidity
Morbidity
and/or
or Mortality
Mortality
or
Minimal
Minimal or None
Minimal
Straightforward
Limited
Limited
Low
Low Complexity
Multiple
Moderate
Moderate
Moderate
Moderate
Complexity
Extensive
Extensive
Extensive
Extensive
High
High Complexity
Complexity
High
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Medical Decision Making
2 of 3 Elements Must
Be Met or Exceeded
Number of
Number
of
Diagnoses/
Diagnoses/
Management
Management
Options
Options
Amount
and/or
Amount and/or
Complexity of
Complexity
of
Data
Data
Risk
of
Type of Medical
Risk of
Complication
Complication
Decision Making
and/or Morbidity
Morbidity
and/or
or Mortality
Mortality
or
Minimal
Minimal or None
Minimal
Straightforward
Limited
Limited
Low
Low Complexity
Multiple
Moderate
Moderate
Moderate
Moderate
Complexity
Extensive
Extensive
Extensive
Extensive
High
High Complexity
Complexity
High
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Medical Decision Making
2 of 3 Elements Must
Be Met or Exceeded
Number of
Number
of
Diagnoses/
Diagnoses/
Management
Management
Options
Options
Amount
and/or
Amount and/or
Complexity of
Complexity
of
Data
Data
Risk
of
Type of Medical
Risk of
Complication
Complication
Decision Making
and/or Morbidity
Morbidity
and/or
or Mortality
Mortality
or
Minimal
Minimal or None
Minimal
Straightforward
Limited
Limited
Low
Low Complexity
Multiple
Moderate
Moderate
Moderate
Moderate
Complexity
Extensive
Extensive
Extensive
Extensive
High
High Complexity
Complexity
High
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Established Patient Visit Requires
2 of 3 Key Components to Be Met
Procedure Code
History
Examination
Medical Decision
Making
99211
N/A
N/A
N/A
99212
Problem Focused
History
Problem Focused
Examination
Straightforward
99213
Expanded Problem
Focused History
Expanded Problem
Focused
Examination
Low Complexity
99214
99214
Detailed History
Detailed
Examination
Moderate
Complexity
99215
Comprehensive
History
Comprehensive
Examination
High Complexity
Complexity
High
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Medical Review

Medical review activities
–
–

Identify and prevent inappropriate billing
Develop interventions to correct problems
Benefits of medical review
–
–
–
–
–
–
Fewer claim denials
Improved case review
Fewer claim reviews
Claim decision predictability
Provider education
Increased program integrity
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Corrective Action

4 types of corrective action
– Local Medical Review Policies
– Edits in claims processing system
– Prepayment review
– Postpayment review
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Inquiries

Inquiries may be by telephone or in writing
 Contractor telephone numbers on Internet
www.cms.hhs.gov/medlearn/tollnums.asp
 Automated Response System
–
–
–
–
–
–
Claims status
Available 24 hours a day
Number of pending and finalized claims
Date and check number of most recent check
Year-to-date amount paid
Educational information
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Five Levels of Appeal





Review
Hearing Officer Hearing
Administrative Law Judge
Departmental Appeal Board
Judicial Review in Federal Court
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Advance Beneficiary Notice
Advance
Beneficiary Notice protects both
physician and patient from unexpected financial
liability when service/item may not be covered as
medically reasonable and necessary
–
Given to patient in advance
– Include patient’s name, date, description of
service or item, and reason payment may be
denied or reduced
– Signed and dated by patient
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Overpayment

Overpayment occurs when Medicare pays more
than the correct amount
 Physicians should send refunds to Medicare as
soon as overpayment discovered
 If Medicare discovers overpayment, refund
requested within 30 days
 If refund not received within 30 days, balance
due is satisfied by withholding future claim
payments
 If you disagree with overpayment, you have the
right to appeal
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Business Relations
 Create and maintain sound business relations
– Review and become familiar with Medicare
contractor, CMS, and Social Security
requirements
– Self monitor when entering contractual
arrangements
– Understand Medicare Program requirements
Visit the Medlearn Web page
Contains many free educational resources
www.cms.hhs.gov/medlearn
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Payment Accuracy

Maintain legible and complete documentation
for all services provided
 Select billing codes carefully
 Ensure that duplicate claims are not submitted
 Refund overpayments without waiting for
notification from Medicare
 Verify the identity of all patients
 Ensure that claims are not submitted for services
rendered at no charge
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Protect Your Practice

Protect your Medicare billing number
 Contact Medicare to update records if you:
–
–
–
–
Have a change in status
Close or relocate an office
Change group members
Reassign benefits

Regularly review claims filed on your behalf
 Take care when referring patients for specialized
care or to receive diagnostic tests or supplies
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Compliance Program

Voluntary tool ensures that practices are
compliant with Medicare requirements

Office of Inspector General guidance available
in Federal Register and at
www.oig.hhs.gov/fraud/complianceguidance.html
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Fraud
Intentional deception or misrepresentation that an
individual knows to be false or does not believe to be true
and makes, knowing that the deception could result in
some unauthorized benefit to himself/herself or some
other person. Some examples of fraud are
Billing for services not furnished or supplies not
provided
Using incorrect or inappropriate provider number
Signing blank records or certifications
Offering incentives to Medicare patients that are not
offered to non-Medicare patients
Selling or sharing patients’ Medicare numbers
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Abuse
Practices that either directly or indirectly result in
unnecessary costs to the Medicare Program.
Abusive practices may develop into fraud if they
were knowingly and willfully committed. Some
examples of abuse





Violating Medicare Participating Physician or Supplier
Agreement
Submitting claims to Medicare that are the responsibility of
other insurers
Charging in excess for services or supplies
Providing medically unnecessary services
Providing services that do not meet professionally recognized
standards
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Administrative Sanctions

Deny or revoke application for Medicare provider number
 Suspend payment
 Civil Monetary Penalties
In cases of substantial fraud or suspected
inappropriate activities:
 Criminal prosecution and penalties
 Civil prosecution and penalties
 Exclusion from the Medicare Program
 Payment denials
 Excluded provider lists
 Corporate integrity agreement
Office of Inspector General Hotline 1-800-HHS-TIPS
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Laws That Impact Medicare

Revised guidelines for teaching physicians
 Anti-Fraud Provisions
– False Claims Act
– Anti-Kickback Statute
– Physician Self-Referral or Stark II Laws
– Safe Harbors for Protecting Health Plans
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Laws That Impact Medicare

Health Insurance Portability and Accountability
Act of 1996
– Visit www.cms.hhs.gov/hipaa/hipaa2
for more information about HIPAA requirements
– Visit www.dhhs.gov/ocr/hipaa
for more information about the privacy of medical
information
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Review
What are Medicare’s 3 parts?
 What are the 3 groups insured by Medicare?

60
Review

What are the 2 identifying numbers physicians
are assigned upon acceptance into the Medicare
Program?
 What are the benefits of becoming a Medicare
participating physician?
 What are the 2 types of claims or requests for
Medicare payment?
61
Review

What are the benefits of Electronic Data
Interchange?
 When does Medicare become the secondary
payer?
62
Review

What method may be used to obtain primary
insurance information?
 When are services or supplies considered
medically necessary?
63
Review

What are the conditions that must be met under
the “Incident to” Provision?
 What does medical documentation facilitate?
64
Review

What are the 3 key components in selecting
levels of Evaluation and Management services?
 What are the benefits of the medical review
process?
65
Review

What are the types of corrective action that
Medicare may take?
 What are the 5 levels in the appeals process?
66
Review

What form should you ask a patient to sign
when you believe that a service or item may not
be covered as medically reasonable and
necessary?
 What are the measures that can help protect a
physician’s practice?
67
Review

What tool should a physician use to ensure
compliance with Medicare requirements?
 What are some examples of fraud?
68
Review

What are some examples of abuse?
 What are the Anti-Fraud Provisions?
69
Review

What are the provisions of the Health Insurance
Portability and Accountability Act?
70
Post-Assessment



Please complete the
Post-Assessment and
Course Evaluation now
Your feedback will help
us improve the Medicare
Resident & New
Physician Training
Program
Thank You!
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