Posts Tagged Medicare Part B

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Getting Paid: Master the ABN Advance Beneficiary Notice


One of the most popular topics I’ve written about over the past 10 years, and the one I get the most email on, is the ins and outs of using the Medicare Advance Beneficiary Notice of Noncoverage – the ABN – also known as form CMS-R-131.

Why is getting an ABN so important?

The answer to this question is simple. If you supply a service to a Medicare patient and Medicare does not pay for it, you can only collect payment from the patient if you’ve communicated to the patient what the cost is and that the cost will be their responsibility AND the patient has agreed. If you routinely supply services to patients that Medicare does not cover and do not use the ABN, your practice will be missing income that is rightfully yours. Read on for more information on the appropriate times to issue ABNs for Medicare (and non-Medicare patients).

Why do practices find it difficult to use ABNs?

The ABN is a collection tool that many medical practices do not know how to implement.  It is particularly difficult to determine who has ownership of this process, because the form must be completed and signed by the patient before the service is provided.  The patient is in the exam room or the lab, ready for the service or test, and a knowledgeable staff person must step in, explain the rules and pricing and obtain the patient’s signature.

Which insurance plans require the ABN?

Although you can use the ABN for Medicare Advantage Plans (commercial insurance plans that offer Medicare replacement coverage) only original/traditional Medicare (sometimes referred to as the “red, white and blue card” Medicare) REQUIRES the ABN.

Commercial non-Medicare plans have also started asking physicians to issue ABNs when a service will not be covered by the plan and the patient will be paying for the service out-of-pocket. I’ve developed a non-Medicare ABN that you are welcome to have a copy of – just drop me an email (marypat@managemypractice.com) and request it. I think ABNs are not a bad idea at all to give to non-Medicare patients as it formalizes the process and drives home to the patient what the cost for something they ask for will be and that they’ve agreed to pay for it.

The ABN is not a replacement for a good financial policy

Please don’t use a blanket ABN in place of a solid financial policy. Your financial policy should state that patients agree to be responsible for payments for services their plans don’t cover. The ABN is meant for specific individual services or series of services that the insurance plan is not going to cover, not as a catch-all for whatever insurance does not pay for. Note that the ABN is not meant to cover any dollars for which you are contractually obligated to write-off.

What version of the ABN is current?

As of last summer (6/21/2017), there is an updated ABN. You should be using the one that has the date of 03/2020 in the lower left-hand corner. In accordance with Section 504 of the Rehabilitation Act of 1973 (Section 504), the form has been revised to include language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed.

Copies of the current ABN are available in English and Spanish here.

Who uses the ABN?

The ABN is to be used by all providers, practitioners, and suppliers paid under Medicare Part B, as well as hospice providers and religious non-medical healthcare institutions (RNHCIs) paid exclusively under Medicare Part A. Since 2013, home health agencies (HHAs) providing care under Part A or Part B issue the ABN instead of the Home Health Advance Beneficiary Notice (HHABN) Option Box 1 to inform beneficiaries of potential liability. The HHABN has been discontinued.

When should the ABN be used?

The ABN’s purpose is to allow the physician practice to collect from the patient for services that the patient wants but are not covered by Medicare. Practices are not expected to give ABNs to patients to cover services that are never covered (called statutory exclusions), however, many practices find that supplying this form to patients helps patients understand why they are responsible for the paying for the service. Practices may collect in full at time of service for services that are never covered by Medicare, but if you are not sure if Medicare will or will not pay, you may want to wait for Medicare to adjudicate the claim before collecting from the patient.

Note that the ABN must be completed and signed BEFORE providing the items or services that are the subject of the notice.

Also note when the ABN is used as a voluntary notice (i.e. for statutory services), the beneficiary is not required to choose an option box or sign the notice.

The four broad categories of items and services not covered under Medicare are:

  1. Services and supplies that are not medically reasonable and necessary
  2. Non-covered items and services (statutory exclusions)
  3. Services and supplies denied as bundled or included in the basic allowance of another service
  4. Items and services reimbursable by other organizations or furnished without charge

The brochure that describes in-depth of what Medicare does not cover is available here.

Can you give an example of when to use an ABN?

A Medicare patient wants an EKG even though she does not have any symptoms or diagnoses that would point to an EKG being medically necessary. She is not in her first 12 months of Medicare coverage, therefore she does not qualify for an EKG as a part of her Welcome to Medicare Visit (not an exam.) She believes there may be something wrong with her heart, even though she cannot name any symptoms that would warrant a diagnostic EKG. In this case, without a diagnosis to support the EKG, an ABN would be appropriate. You would advise the patient that Medicare may not pay for the EKG, in fact probably won’t pay for the EKG, and you complete the ABN, showing the patient what she will be paying out of pocket for the test. In the case of Medicare not covering the test, you may charge the patient your full rate for an EKG and are not restricted by the Medicare allowable. If the patient agrees to have the test and signs the ABN stating she understands she will be responsible for the cost of the test if Medicare does not pay, you will provide the patient with a copy of the signed form and will will attach the completed form to the patient’s encounter form or somehow note in the EMR that an ABN has been obtained so the EKG will be billed with the modifier “GA” which indicates an ABN was executed for a service that might not be covered by Medicare. In the case where a service is never covered (i.e. statutory exclusions) you may append a modifier “GY” to the service to indicate an ABN is on file.

The ABN can be scanned with the encounter form or any other financial paperwork from the visit so it can be retrieved if requested by Medicare during an audit. If you do not archive your paperwork electronically, you can file the ABNs alphabetically by patient name by month. You can also scan the ABN into your EMR if you choose.

What are statutory exclusions (services that are never covered) under Part B?

  • Oral drugs and medicines from either a physician or a pharmacy. Exceptions: oral cancer drugs, oral antiemetic cancer drugs and inhalation solutions.
  • Routine eyeglasses, eye examinations, and refractions for prescribing, fitting, or changing eye glasses. Exceptions: post cataract surgery. Refer to benefits under DME prosthetic category.
  • Hearing aids and hearing evaluations for prescribing, fitting, or changing hearing aids.
  • Routine dental services, including dentures.
  • Routine foot care without evidence of a systemic condition.
  • Injections which can be self-administered. Exceptions: EPO, and clotting factors.
  • Naturopath’s services.
  • Nursing care on a full-time basis in the home and private duty nursing. (Refer to benefits under Medicare Part A).
  • Services performed by immediate relatives or members of the household. Services payable under another government program.
  • Services for which neither the patient nor another party on his or her behalf has a legal obligation to pay.
  • Immunizations. Exceptions: Influenza, Pneumovax and Hepatitis B.
  • Wheelchair van ambulance services.
  • Cosmetic surgery.
  • “Annual Physicals” best described by codes 99387 or 99397. This is a long discussion for another post, but note that Medicare does not pay for annual preventive EXAMINATIONS, although they pay for annual wellness visits, which are not physical examinations. They do, however, pay for screening pelvic and breast exams and pap test collection at specific intervals.

How do you complete the “Estimated Cost” Section F of the ABN?

Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed under Blank (D). CMS expects that the estimate should be within $100 or 25% of the actual costs, whichever is greater; however, an estimate that exceeds the actual cost substantially would generally still be acceptable, since the beneficiary would not be harmed if the actual costs were less than predicted. Thus, examples of acceptable estimates would include, but not be limited to, the following:

For a service that costs $250:

  • Any dollar estimate equal to or greater than $150
  • “Between $150-300”
  • “No more than $500”

For a service that costs $500:

  • Any dollar estimate equal to or greater than $375
  • “Between $400-600”
  • “No more than $700”

What about estimating the costs for a series of services?

Multiple items or services that are routinely grouped can be bundled into a single cost estimate. For example, a single cost estimate can be given for a group of laboratory tests, such as a basic metabolic panel (BMP). An average daily cost estimate is also permissible for long term or complex projections. As noted above, providers may also pre-print a menu of items or services in the column under Blank (D) and include a cost estimate alongside each item or service. If a situation involves the possibility of additional tests or procedures (such as in laboratory reflex testing), and the costs associated with such tests cannot be reasonably estimated by the notifier at the time of ABN delivery, the notifier may enter the initial cost estimate and indicate the possibility of further testing. Finally, if for some reason the notifier is unable to provide a good faith estimate of projected costs at the time of ABN delivery, the notifier may indicate in the cost estimate area that no cost estimate is available. We would not expect either of these last two scenarios to be routine or frequent practices,but the beneficiary would have the option of signing the ABN and accepting liability in these situations.

How do I use modifiers to indicate the ABN is present?

The modifiers can be confusing! Focus on using the GA and GX modifiers as best practice.

GA Modifier – Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case – ABN Needed and Obtained

Use this modifier to report that an advance written notice was provided to the beneficiary of the likelihood of denial of service as being not reasonable and necessary under Medicare guidelines.

  • Report when you issue a mandatory ABN for service as required and is on file.
  • You do not need to submit a copy of the ABN but it must be available upon request.
  • The most common example of these situations would be services adjudicated under a Local Coverage Decision (LCD).
  • The presence or absence of this modifier does not influence Medicare’s determination for payment.
  • Line item is submitted as covered and Medicare will make the determination for payment.
  • If it’s determined that the service is not payable, the claim denial is under “medical necessity denial.”
  • It is inappropriate to use the GA modifier when the provider/supplier has no expectation that an item or service will be denied.
  • Do not use on a routine basis for all services performed by a provider/supplier.

GX Modifier – Notice of Liability Issued, Voluntary Under Payer Policy – No ABN Needed But Was Issued Nonetheless

Use this modifier to report when you issue a voluntary ABN for a service that Medicare never covers because it is statutorily excluded or is not a Medicare benefit.

  • Line items submitted as non-covered will be denied as beneficiary liable.
  • You may use this modifier in combination with the GY modifier.

GY Modifier – Item or Service Statutorily Excluded, Does Not Meet the Definition of Any Medicare Benefit – No ABN Needed and None Issued

Use this modifier to report that Medicare statutorily excludes the item or service or the item or service does not meet the definition of any Medicare benefit. Use this modifier to notify Medicare that you know this service is excluded.

  • Services provided under statutory exclusion from the Medicare Program; the claim would deny whether or not the modifier is present on the claim.
  • It is not necessary to provide the patient with an ABN for these situations.
  • Situations excluded based on a section of the Social Security Act.
  • Modifier GY will cause the claim to deny with the patient liable for the charges.
  • Do not use on bundled procedure or on add-on codes.
  • Line items submitted as non-covered and will be denied as Patient Responsibility
  • You may use this modifier in combination with the GX modifier.

 GZ Modifier – Item or Service Expected to Be Denied as Not Reasonable and Necessary – ABN Needed But Not Obtained

Use this modifier to report when you expect Medicare to deny payment of the item or service due to a lack of medical necessity and no ABN was issued.

  • This modifier is an informational modifier only.
  • Medicare will adjudicate the service just like any other claim.
  • If Medicare determines that the service is not payable, denial is under “medical necessity.” The denial message will indicate that the patient is not responsible for payment.
  • If either the beneficiary or provider requests a review, the modifier tells us an ABN was not given, and this could help in completing the review quickly.
  • Medicare will auto-deny services submitted with a GZ modifier. The denial message indicates that the patient is not responsible for payment; deny provider liable.
  • If either beneficiary or provider requests a review, the modifier tells us that an ABN was not given.

For in-depth instruction from Medicare on completing the ABN, click here.

Photo Credit: Photo Credit: Diari La Veu – http://diarilaveu.com Flickr via Compfight cc

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2013 Medicare Parts A, B, C and D Deductibles and Premiums

The Part B Medicare deductible for 2013 is $147.00.

Medicare Premiums for 2013 Are Here! Celebrate with cake!

What should you do with this information? You should avoid taking a big financial hit in the first quarter of 2013 by collecting deductibles at time of service. How do you do that?

  • Let all patients know in advance that you collect deductibles by making it part of your communication with them. Put it in your financial policy (get a copy of my preferred financial policy below), put it on your website, and let patients know when you schedule their appointment, or make an appointment reminder with verbiage like:

“We look forward to seeing you at your appointment. Please bring your insurance cards and all medications to your visit. We will collect your co-pay, your deductible, and any co-insurance required by your insurance plan.”

  • Explain what a deductible is. Get my sample patient handout explaining deductibles below.
  • Train front desk staff on deductibles and get them comfortable discussing deductibles with patients and answering their questions.
  • Do not collect deductibles for Medicare patients who also have Medicaid, or for Medicare patients with supplemental insurance as there most likely will not be a balance that the patient will owe.
  • It is ideal to use a Credit Card On File program to charge the patient’s credit card at time of service, or when the EOB (Explanation of Benefits) arrives in 15 days.

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2013 OIG Workplan: You’re Doing it Wrong

OFFICE OF INSPECTOR GENERAL DEPARTMENT OF HEALTH AND HUMAN SERVICES SEAL

 

 

 

 

 

 

 

 

 

The 2013 Work Plan for the OIG has been released and here are some of the top items that relate to medical practices. This is a great list to use for review and discussion – Is your medical practice doing this correctly?

Incident-To Services Performed by Nonphysicians

Reasons why practices are not billing these services correctly:

  • Lack of understanding of incident-to
  • Trying to avoid the 15% reduction in reimbursement for services provided by credentialed nonphysicians
  • Difficulty in documenting who provided the services for charge entry

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Posted in: Collections, Billing & Coding, Compliance, Medicare & Reimbursement, Medicare This Week

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Medicare News for the Week of February 13, 2012: PQRS, eRX and EHR, EHR and EHR

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Posted in: Electronic Medical Records, Headlines, Medicare & Reimbursement, Medicare This Week

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2012 Medicare Deductibles and Premiums: Is This the Year You’ll Collect Deductibles at Time of Service?

CMS just announced the new numbers for premiums and deductibles for 2012. Now is the ideal time to think about Medicare deductibles and what your policy is on collecting deductibles at time of service.

If you’ve been hesitant to collect deductibles, ask yourself if you can handle the loss or delay of payment of $140 per Medicare patient. Most practices can’t. If you are thinking about collecting deductibles and other front-end collection techniques, my book “The Smart Manager’s Guide to Collecting at Checkout” is your guide to making it happen for your healthcare group. Click here to read more.

MEDICARE PART B (covers a portion of the cost of physicians’ services, outpatient hospital services, certain home health services, durable medical equipment, and other items)

  • In 2012, the Part B deductible will be $140, a decrease of $22 from 2011.
  • The standard Medicare Part B monthly premium will be $99.90 in 2012, a $15.50 decrease over the 2011 premium of $115.40.
  • The standard premium is set to cover one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over, plus a contingency margin. The contingency margin is an amount to ensure that Part B has sufficient assets and income to (i) cover Part B expenditures during the year, (ii) cover incurred-but-unpaid claims costs at the end of the year, (iii) provide for possible variation between actual and projected costs, and (iv) amortize any surplus assets.  Most of the remaining Part B costs are financed by Federal general revenues.  (In 2012, about $2.9 billion in Part B expenditures will be financed by the fees on manufacturers and importers of brand-name prescription drugs under the Affordable Care Act.)
  • The largest factor affecting the contingency margin for 2012 is the current law formula for physician fees, which will result in a payment reduction of about 29 percent in 2012.  For each year from 2003 through 2011, Congress has acted to prevent smaller physician fee reductions from occurring. The 2012 reduction is almost certain to be overridden by legislation enacted after Part B financing has been set for 2012. In recognition of the strong possibility of increases in Part B expenditures that would result from similar legislation to override the decrease in physician fees in 2012, it is appropriate to maintain a significantly larger Part B contingency reserve than would otherwise be necessary.  The asset level projected for the end of 2012 is adequate to accommodate this contingenIn 2012, Social Security monthly payments to enrollees will increase by 3.6 percent.    The dollar increase in benefit checks is expected to be large enough on average to cover the increase in the Part B premium of $3.50 that most beneficiaries will experience. For those who were paying the standard premium of $115.40, their benefits checks will only increase.

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My Notes on Today’s CMS Call on the Initial Preventive Physical Exam (Not a Physical Exam) and the Annual Wellness Visit

Today’s CMS call reviewed the guidelines for the IPPE (Initial Preventive Physical Exam) and the AWV (Annual Wellness Visit), what they include and how to code for them.

What is the IPPE (also called the “Welcome to Medicare Visit”)?

The IPPE is a one-time visit, covered within 12 months after the effective date of Part B coverage and including:

  • Review of medical and social history.
  • Review of risk factors for depression.
  • Review of functional ability and level of safety.
  • Measurement of height, weight, body mass index, blood pressure, visual acuity, and other factors deemed appropriate.
  • Discussion of end-of-life planning, if agreed upon by the patient.
  • Education, counseling and referrals based on results of review and evaluation services performed during the visit, including a brief written plan such as a checklist, and if appropriate, education, counseling and referral for obtaining an electrocardiogram (a/k/a EKG, ECG).
  • Note that although the IPPE has the word “exam” in it, there is NO physical exam associated with it. Most practices attempt to call it the Welcome to Medicare Visit and try never to use the word “exam” in association with it.

Who can provide the IPPE?

  • Physician (doctor of medicine or osteopathy)
  • Qualified non-physician practitioner including nurse practitioner physician assistant or Clinical nurse specialist

How is the IPPE Billed?

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Step by Step Directions for Getting the EHR Incentive Money: My Notes From Last Week’s CMS Call

First the facts on what has taken place so far in the 2011 EHR Incentive Programs.

  • As of June 30th, the total of Medicare EHR Incentive Program payments is over $94 million.
  • As of June 30th, over $166 million has been paid in Medicaid EHR incentives since the program began in January.  In May and June, four states launched Medicaid EHR Incentive Programs – Indiana, Ohio, Pennsylvania, and Washington, bringing the total states with Medicaid EHR Incentive Programs to 21.  More states will launch in July.
  • There are 68,001 active registrations of eligible professionals and eligible hospitals for the Medicare and Medicaid EHR Incentive Programs.

If your group hasn’t received a check and hasn’t registered for the Medicare or Medicaid Incentive Program, then this blog post is for you! For anyone who is really just beginning their EHR journey, today’s presentation clarified previous information given by CMS, as well as giving listeners new information about the programs.

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Posted in: Electronic Medical Records, Medicare & Reimbursement, PECOS

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Medicare 2011: What’s Covered and How Physician Practices Can Deal With the Changes

More information on Medicare wellness visits in 2011 can be found here.

Information on the 2011 Medicare Part A and Part B deductibles and  premiums can be found here.

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The extensive changes coming for Medicare Part B coverage in 2011 should have primary care practices and some specialty practices thinking about their current processes.  If you meet with your team now to educate them about the Medicare changes and explore process tweaking, you’ll be ready when January 1 rolls around.

Attending surgeon's office; examination room, ...

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Here are a few areas to think about:

  1. Advance Beneficiary Notices (ABNs) – Many practices struggle with the who and when of ABNs and the new coverage might not make it easier.  There are lots of services now covered with new frequency limitations, so practices must be on their toes to recognize when a service is covered and when it isn’t.  Sure, you can ignore ABNs and wait for Medicare to tell you a service is not covered, but then it’s too late to collect from the patient – not only too late, but also illegal to collect.
  2. The annual wellness visit is going to be a special challenge because the timing is precise.  Medicare patients will hear “annual visit”, but won’t realize it will not be paid for if performed within 12 months of a previous wellness visit (Welcome to Medicare exam or annual visit).  I’ve not seen any practice management software that handles this really well, but maybe it’s out there.  I’d love to see Medicare patients scheduling their annual visits during their birthday month so staff would have a fighting chance of identifying the last annual visit and getting the date right.  Of course, using your electronic recall will work too if you schedule the next year’s visit when the patient is checking out. (Do you proactively contact your Medicare patients to invite them to come in for their Welcome to Medicare exam?) Also encourage patients to keep up with the preventive services they are eligible to receive by registering with the My Medicare website (https://mymedicare.gov/).  This is their personal Medicare website for tracking their Medicare services.  It will send them e-mail reminders when they are eligible for Medicare coverage of preventive services.  Great idea!
  3. Who will be doing the counseling about the “preventive services covered by Medicare” during the annual exam?  Let’s hope Medicare puts out a really great handout!
  4. Most EMRs will let you load requirements for services based on diagnosis – for example, diabetes.  Make sure you are taking advantage of the EMR’s ability to set up protocols for age, diagnosis and risk factors. If you are not on EMR yet, use your appointment schedule or recall system to set reminder appointments to contact patients for their services.
  5. Don’t forget your patients on Medicare who are not yet age 65. Run a report to find these patients and flag them to acknowledge that their Medicare services are at different times.
  6. Collections at time of service will change too, of course, as most services listed below will not be applied to the deductible.  Exceptions are glaucoma screening, diabetes monitoring and education, medical nutritional, and smoking cessation.  Patients understandably will be confused, so make sure your check-out staff are crystal clear.

Medicare Benefits Beginning January 1, 2011

  • Medicare covers a one-time preventive physical exam within the first twelve months of having Part B.  The exam will include a thorough review of  health, education and counseling about the preventive services covered by Medicare and referrals for other care if needed.  No Part B deductible and effective January 1, 2011 you pay nothing if the doctor accepts assignment.
  • Abdominal Aortic Aneurysm Screening – People at risk for abdominal aortic aneurysms may get a referral for a one-time screening ultrasound at their “Welcome to Medicare” physical exam.  Effective January 1, 2011 no deductible and no copayment.
  • New Annual Wellness Visit – Effective January 1, 2011 Medicare will cover an Annual Wellness Visit that includes a thorough review of health, education and counseling about the preventive services covered by Medicare and referrals for other care if you need it.  It is available every 12 months (after first 12 months of Part B coverage) but not within 12 months of receiving either a “Welcome to Medicare” physical exam or another Annual Wellness Visit.  No Part B deductible ”“ Medicare pays 100% of the approved amount.
  • Cardiovascular Screening Blood Tests –  Medicare covers cardiovascular screening tests that check cholesterol and other blood fat (lipid) levels every 5 years.  Includes:
    • Total Cholesterol Test
    • Cholesterol Test for High Density Lipoproteins; and
    • Triglycerides Test
    • No Part B deductible ”“ Medicare pays 100% of approved amount.
  • Diabetes Screening Tests – Anyone enrolled in Medicare identified as “high risk” for diabetes will be able to receive screening tests to detect diabetes early.  Covers up to two screenings each year.  Includes:
    • Fasting plasma glucose test
    • Post-glucose challenge test
    • No Part B deductible ”“ Medicare pays 100% of approved amount
  • Glaucoma Screening – Must be done or supervised by an eye doctor (optometrist or ophthalmologist). Covered annually for:
    • Those with diabetes
    • Those with a family history of glaucoma
    • African-Americans age 50 and older
    • Hispanic-Americans age 65 and older
    • Other high risk individuals
    • Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.
  • Bone Mass Measurement – For those enrolled in Medicare at high risk for losing bone mass.  Effective January 1, 2011 no Part B deductible ”“ Medicare pays 100% of approved amount.
  • Screening Mammography (including new digital technologies) – For women age 40 and older enrolled in Medicare:
    • Covered annually
    • No Part B deductible ”“ Medicare pays 100% of approved amount beginning January 1, 2011.
  • Screening Pap Test & Pelvic Examination (Includes clinical breast examination) – For all women enrolled in Medicare:
    • Covered once every two years for most
    • Covered annually for women at high risk
    • No Part B deductible ”“ Medicare pays 100% of approved amount for Pap test and effective January 1, 2011 pays 100% of approved amount for pelvic and breast exam.
  • Colorectal Cancer Screening – For all those enrolled in Medicare age 50 and older:
    • Fecal-Occult blood test covered annually ”“ No Part B deductible & Medicare pays 100% of approved amount.
    • Flexible sigmoidoscopy once every four years or 10 years after a previous screening colonoscopy”“ No Part B deductible or copayment starting January 1, 2011.
    • Barium enema can be substituted for sigmoidoscopy or colonoscopy ”“ No Part B deductible – Medicare pays 80% of the approved amount.  You will pay a higher coinsurance if the test is done in a hospital outpatient department.
    • Colonoscopy for any age enrolled in Medicare
    • Average risk – Once every ten years, but not within four years after a screening flexible sigmoidoscopy
    • High-risk – Once every two years
    • No Part B deductible and effective January 1, 2011 Medicare pays 100%.
  • Prostate Cancer Screening Tests -For all men enrolled in Medicare age 50 and older:
    • Covered annually
    • Digital rectal exam ”“ Medicare pays 80%  of the approved amount after the deductible
    • Prostate Specific Antigen (PSA) test
    • No Part B deductible – Medicare pays 100% of approved amount.
  • Diabetes Monitoring and Education – Covers Type I and Type II diabetics enrolled in Medicare who must monitor blood sugar (Not paid for those in a nursing home) Covered services:
    • Glucose-monitoring devices, lancets & strips
    • Education & training to help control diabetes
    • Foot care once every 6 months for those with peripheral neuropathy
    • Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.
  • Medical Nutritional Therapy – Covered for those with diabetes or kidney disease. Includes diagnosis of special nutrition needs, therapy and counseling services to help you manage your disease.  Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.

Thank you for smoking

  • Smoking Cessation Services – Medicare will cover up to 8 counseling sessions per year for individuals who have an illness caused or complicated by tobacco use or you take medication affected by tobacco use.  Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.
  • Flu Vaccination Annually (Medicare pays once per season. You do not have to wait 365 days since your last one.) No Part B deductible ”“ you pay nothing if your doctor accepts assignment. My post on billing for the flu shot is here.
  • H1N1 Flu Vaccine Medicare covers the administration of the H1N1 flu shot.  You cannot be charged for the vaccine.  No Part B deductible or co-insurance.
  • Pneumococcal Pneumonia Vaccination– Once per lifetime for all enrolled in Medicare.  (A doctor may order additional ones for those with certain health problems.) No Part B deductible ”“ Medicare pays 100% of approved amount.
  • Hepatitis B Shots – Covered for those who are at medium or high risk.  Effective January 1, 2011, there will be no Part B deductible and Medicare pays 100%.

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Medicare for 2010: Deductibles and Premiums Update

Medicare is a federal health insurance program created in 1965 for:

  • people age 65 or older,
  • people under age 65 with certain disabilities, and
  • people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

Medicare Part A – 99% of patients don’t pay a premium for Part A (hospital insurance) because they or a spouse already paid for it through their payroll taxes while working. The ,100 deductible for 2010, paid by the beneficiary when admitted as a hospital inpatient, is an increase from 2009.   Part A helps cover:

  • inpatient care in hospitals (excluding the physician fees), including critical access hospitals
  • skilled nursing facilities (not custodial or long-term care)
  • some hospice care
  • some home health care


Medicare Part B
– Part B (outpatient/doctor insurance) base premium for 2010: .40/month (no change from 2009.)  Premiums are higher for single people over 65 making more than K per year and for couples making over 0K.  Part B premiums cover approximately one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over.  The remaining Part B costs are financed by Federal general revenues.  In 2010, the Part B deductible is 5.  Part B helps cover:

  • physician fees in the hospital
  • physician fees in their offices and other outpatient locations
  • other outpatient services (x-rays, lab services)
  • some services of physical and occupational therapists
  • some home health care

Medicare Part C – Medicare now offers beneficiaries the option to have care paid for through private insurance plans.  These private insurance options are part of Medicare Part C, which was previously known as Medicare+Choice, and is now called Medicare Advantage. Medicare Advantage expands options for receiving Medicare coverage through a variety of private insurance plans, including private fee-for-service (PFFS) plans, local health maintenance organizations (HMOs) and regional preferred provider organizations (PPOs), and through new mechanisms such as medical savings accounts (MSAs), as well as adding payment for additional services not covered under Part A or B.

Medicare Part D –  Starting January 1, 2006, Medicare prescription drug coverage became available to everyone with Medicare.  The so-called “doughnut hole” is the amount the patient pays between the initial coverage limit of ,830 and the out-of-pocket threshold of ,550 – a total of 20 that the patient is responsible for.

  • Initial Deductible: 0
  • Initial Coverage Limit: ,830
  • Out-of-Pocket Threshold: ,550


COMPARISON OF MEDICARE PLANS

Original Medicare Plan

WHAT? The traditional pay-per-visit (also called fee-for-service) arrangement available nationwide.

HOW? Providers can choose to participate (“par”) or not participate (“non-par”.)  Participating providers accept the Medicare allowable and collect co-insurance (20% of the allowable.) Reimbursement comes to the providers.  Non-participating providers may charge 15% more (called the “limiting” charge) than the Medicare allowable schedule, but the patient will receive the check, which is why some non-par practices require payment at time of service for Medicare patients. To be able to charge patients for non-covered services, patients must sign an ABN before the service is provided.

Original Medicare Plan With Supplemental Medigap Policy

WHAT? The Original Medicare Plan plus one of up to ten standardized Medicare supplemental insurance policies (also called Medigap insurance) available through private companies.

HOW? Medigap plans may cover Medicare deductibles and co-insurance, but typically will not cover anything Medicare will not.  Medicare primary claims will “cross-over” to many Medigap secondary claims so the practice does not have to file the secondary Medigap claim.  Patients may still have a small balance that is cost-prohibitive to bill for.

Medicare Coordinated Care Plan

WHAT? A Medicare approved network of doctors, hospitals, and other health care providers that agrees to give care in return for a set monthly payment from Medicare. A coordinated care plan may be any of the following: a Health Maintenance Organization (HMO), Provider Sponsored Organization (PSO), local or regional Preferred Provider Organization (PPO), or a Health Maintenance Organization (HMO) with a Point of Service Option (POS).

HOW? You have to have signed a contract or be grandfathered in (called an “all-products” clause) under an existing contract to see patients and get paid. Primary care providers may have to provide referrals and/or authorization for specialty services and providers. A PPO or a POS plan usually provides out of network benefits for patients for an extra out-of pocket cost.

Private Fee-For-Service Plan (PFFS)

WHAT? A Medicare-approved private insurance plan. Medicare pays the plan a premium for Medicare-covered services. A PFFS Plan provides all Medicare benefits. Note: This is not the same as Medigap.

HOW? Most PFFS plans allow patients to be seen by any provider who will see them. PFFS plans do not have to pay providers according to the prevailing Medicare fee schedule or pay in 15 days for clean claims.  Providers may bill patients more than the plan pays, up to a limit. It would be a good thing to notify patients if your practice intends to bill above the plan payment.

Need more?  Click on CMS (provider-oriented) or Medicare (patient-oriented.)

Posted in: Day-to-Day Operations, Finance, Medicare & Reimbursement

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