Posts Tagged Part B

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The Medicare News You Can Use This Week: eRx Exemptions for 2012 and 2013, Billing Education, and eSignatures

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Posted in: Compliance, Day-to-Day Operations, Electronic Medical Records, Headlines, Medicare & Reimbursement, Medicare This Week, PECOS

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The Best of Manage My Practice – October, 2011 Edition

As we finish off another month here at MMP, we wanted to go back over some of our most popular posts from the month and get ready for another busy,  productive, and meaningful month. Presenting, The Best of Manage My Practice, October 2011!

We’ve started this monthly wrap-up to make sure you don’t miss any of the great stuff we post throughout the month on Manage My Practice, but we also want to hear from you! What were your favorite posts and discussions this month? Did we skip over your favorite from October? Let us know in the comments!

Posted in: A Career in Practice Management, Collections, Billing & Coding, Day-to-Day Operations, Finance, General, Medicare & Reimbursement

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Medicare 2011 Part A and Part B Premiums, Deductibles and Coinsurance

Hospital

Click here for the 2012 Medicare Part A and Part B Premiums and Deductibles.

 

 

Medicare Premiums for 2011:

Part A: (Hospital Insurance) Premium

  • Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.
  • The Part A premium is $248.00 per month for people having 30-39 quarters of Medicare-covered employment.
  • The Part A premium is $450.00 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.

Part B: (Medical Insurance) Premium

Most beneficiaries will continue to pay the same $96.40 or $110.50 premium amount in 2011.  Beneficiaries who currently have the Social Security Administration (SSA) withhold their Part B premium and have incomes of $85,000 or less (or $170,000 or less for joint filers) will not have an increase in their Part B premium in 2011.  For additional details, see the FAQ titled:

For all others, the standard Medicare Part B monthly premium will be $115.40 in 2011, which is a 4.4% increase over the 2010 premium.  The Medicare Part B premium is increasing in 2011 due to possible increases in Part B costs.  If their income is above $85,000 (single) or $170,000 (married couple), then the Medicare Part B premium may be higher than $115.40 per month.

Medicare Deductible and Coinsurance Amounts for 2011:


Part A: (pays for inpatient hospital, skilled nursing facility, and some home health care) For each benefit period Medicare pays all covered costs except the Medicare Part A deductible (2011 = $1,132) during the first 60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days.

For each benefit period you pay:

  • A total of $1,132 for a hospital stay of 1-60 days.
  • $283 per day for days 61-90 of a hospital stay.
  • $566 per day for days 91-150 of a hospital stay (Lifetime Reserve Days).
  • All costs for each day beyond 150 days

Skilled Nursing Facility Coinsurance

  • $141.50 per day for days 21 through 100 each benefit period.

Part B: (covers Medicare eligible physician services, outpatient hospital services, certain home health services, durable medical equipment)

  • $162.00 deductible for 2011. Patients pay 20% of the Medicare-approved amount for services after meetingthe the $162.00 deductible.

Check out the new services that Medicare will cover as of January 1, 2011 here.

Posted in: Medicare & Reimbursement

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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%.

Posted in: Electronic Medical Records, Medicare & Reimbursement

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My Notes from the CMS Open Door Forum on May 19, 2010: PECOS, DMEPOS and Blue Ink on Paper Forms

CMS held a two-hour Open Door Forum today and there was so much good information shared that I thought I’d pass my notes from the call along to you.

New EFT Form

The revised EFT (Electronic Funds Transfer) authorization form 588 is available here (pdf.) The old form will still work for a few months longer before it becomes invalid.

Changes to the Medicare Program Integrity Manual

The Program Integrity Manual (publication 100-08) will have revisions related to the changes in provider enrollment.  The online-only manual here will have content moved from Chapter 10 to Chapter 15 and the provider enrollment information will be easier to understand. 🙂

The Question on Everyone’s Lips

How do I know if I’m listed in PECOS (Provider Enrollment and Chain/Ownership System) and how do I know if others are listed in PECOS?  A new downloadable file is now available here (12,000 pages!) and everyone listed in this Ordering/Referring file has approved enrollment status.  Anyone not appearing on this list is not in approved status, or has opted completely out of the Medicare program.

Advanced Diagnostic Imaging

Beginning in January 2012, all diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging such as positron emission tomography (PET) must be performed in a facility accredited by the American College of Radiology (ACR), The Joint Commission (TJC) or the Intersocietal Accreditation Commission (IAC) for the technical component of the test to be reimbursed by Medicare.  This rule does not apply to x-rays, ultrasound, fluoroscopy, mammography or DEXA scans and does not apply to any professional component.

Hospital Revalidations

Hospitals not enrolled in PECOS or not receiving EFT (Electronic Funds Transfer) will be contacted by CMS in an attempt to get all hospitals revalidated.

PECOS (pronounced “pay-cose”)

CMS recommends that anyone with questions or just getting started in PECOS read the “Getting Started Guide”, of which there are two versions, both available here in pdf form.  One is for providers and one is for suppliers of DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.) You need to know your corporate structure before getting started because the business must enroll before the providers can assign benefits to the business.  The 855I is for individual/solos providers and the 855B is for non-individuals (multiple owners) billing Medicare Part B and assigning benefits to a legal entity/corporation.  Dentists and pediatricians who order or refer services for Medicare patients are required to have an enrollment record in the PECOS. Residents and interns are exempt from the enrollment requirement, but an attending physician needs to be identified on the claim when a service is ordered or referred. The main page for enrollment is https://www.cms.gov/MedicareProviderSupEnroll/

Two Ways to Get Into PECOS

One is to complete the paper form in BLUE INK (and if time is of the essence CMS suggests that you use the paper form) and let the MAC enter it into PECOS for you.  The other is to use the internet-PECOS system directly, and sign, date and mail the certification statement to complete the process.  Submit the participation form or EFT form if required.  The certification form for the paper process is NOT the same as the certification from for the internet-PECOS process.

What is the 30-day rule?

The 30-day rule states that you can bill for services provided to Medicare patients up to 30 days prior to your filing date.  The filing date is the date your enrollment is accepted, not the date you mailed it.  Online it will say “Status Approved”, and you will receive an email, and then a letter confirming it. You will appear on the Ordering/Referring file on the CMS website.

What happens to payments for patients that were referred by a provider not enrolled on PECOS?

Even though you are enrolled, if the referring physician is not enrolled, you will not be paid for that patient’s services.  However, if that referrer becomes enrolled, you can resubmit the claim and it will be paid.

What happens on July 6, 2010? When does this happen?

July 6, 2010 The compliance date for Part A providers (hospitals, skilled nursing homes and home health agencies) and Part B providers (physicians, ambulance) must be enrolled in PECOS as ordering/referring physicians for payments to be made has been delayed indefinitely!

What happens on July 13, 2010?

DMEPOS (pronounced “demmy-pos”) providers must be enrolled in PECOS to receive Medicare payments.

What should be done if a provider leaves a group?

The provider or his Authorized Official (CEO, CFO, Manager) should file a 855R or make the change in PECOS as soon as possible.

Why do provider offices still request UPINs from our office?

Unclear.  UPINs were no longer required as of May 23, 2008.  The NPI is the only number accepted on Medicare claims.

Should the information submitted on a 855 be the same information in PECOS?

Yes, if it isn’t, contact the Help Desk.  Their toll-free number is 1-866-484-8049 and their e-mail address is eussupport@cgi.com.

For more information on the nuts and bolts of PECOS, see my post here.

Posted in: Headlines, Medicare & Reimbursement, PECOS

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The RAC Outreach Session: Get Your Medical Practice Ready Now!

Today I was fortunate enough to attend an outreach session designed to educate hospitals, physicians and other providers about Recovery Audit Contractors (RAC), specifically Connolly Consulting, the RAC for North Carolina.  Although I cannot vouch that the information I am sharing for Region C will be consistent for the other three RACs, the fact that there is a standard handout being used for all RAC outreach sessions makes me think there’s a very good chance that CMS is encouraging a high level of consistency.

If you read the recent Manage My Practice article here by Carla Hannibal, you already know that the RACs were established after CMS demonstration projects proved “to be successful in returning dollars to the Medicare Trust Funds and identifying monies that need to be returned to providers. It has provided CMS with a new mechanism for detecting improper payments made in the past, and has also given CMS a valuable new tool for preventing future payments.” (CMS website)

Each RAC bid for and won the jurisdiction as follows:

  • Region A: CT, DE, DC, MD, ME, MA, NH, NJ, NY, PA, RI, VT Diversified Collection Services (DCS) -1-866-201-0580, website here
  • Region B: MN, WI, IL, IN, OH, MI, KY CGI Technologies and Solutions -1-877-316-7222, website here
  • Region C: AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, SC, TN, TX, VA, WV and the territories of Puerto Rico and U.S. Virgin Islands. Connolly Consulting, Inc. -1-866-360-2507, website here
  • Region D: WA, OR, ID, CA, NV, MT, WY, UT, AZ, ND, SD, NE, KS, IA, MO, AK, HI HealthDataInsights, Inc.-Part A: 866-590-5598, Part B: 866-376-2319, e-mail: website here

Each RAC is required to provide outreach education sessions in their region prior to sending out any letters.   Any hospital or physician who bills fee-for-service programs (Part A and/or Part B) for Medicare beneficiaries is eligible for a RAC audit.

These are the important points that I took away from attending this outreach program:

  1. RACs may review claims as far back as October 1, 2007.
  2. RACs review claims after they have been paid using the same Medicare policies used to pay the claim initially.
  3. There are two types of reviews: Automated Reviews which do not request the medical record and Complex Reviews which will request the medical record.
  4. Automated Reviews are “done deals” and the claim will be adjudicated and a letter sent detailing the dollars requested.
  5. Providers may return the payment by writing a check, allowing a recoupment from future payments or may apply for an extended payment plan.
  6. Complex Reviews entail a request for medical records.  Records can be mailed, faxed, or sent on a CD/DVD.  Mailed records must be sent in a tamper-proof package, and should be sent via trackable carriers (FedEx, UPS, Registered USPS.)  Multiple records may be sent in one package if each record set is in a separate envelope inside the package.
  7. Note: if faxing, fax the records to yourself to check for readability before you fax to the RAC.
  8. Email records are currently not acceptable due to HIPAA.
  9. Providers have 45 days plus 10 mailing days for a total of 55 days to send the records, but extensions are available if this is not abused.  If you do not communicate with your RAC about any problems you are having sending the records (e.g. you can’t find the record!), you risk having the claim(s) automatically recouped.  The Connolly representative even mentioned something to the effect that she wasn’t above calling the practice/entity CEO to let them know that their contact person wasn’t playing by the rules.
  10. Once a claim has been reviewed and a Complex Review is in play, the provider will receive a Demand Letter from the RAC and the provider will have a “discussion period” to contact the RAC and ask questions and/or provide additional information.  The RAC representative emphasized to communicate, communicate, communicate and to call the RAC and  speak to the reviewer of the claim.  Once you have spoken to the reviewer, if you still disagree with the decision, you should ask to speak to the supervisor, and if there still is no agreement, you need to file an appeal.
  11. Appeals must be filed within 120 days of the receipt of the demand letter from the RAC.

Here is a suggested action plan for physician practices to prepare for the RAC process:

  1. Visit the CMS website here and click on Demonstration Projects to see what improper payments were found by the RAC demonstration projects.
  2. Visit the CMS and OIG websites to see what improper payments were found by reading the OIG (Office of Inspector General) reports here and CERT (Comprehensive Error Rate Testing) reports here.
  3. Conduct an internal assessment to see if you are in compliance with Medicare rules, and if not, identify corrective actions needed to bring your group into compliance.  Corrective actions may include provider education and a periodic internal audit to rate the improvement.
  4. Provide your RAC (they will tell you how to do this) with a contact person who will receive RAC letters and who will be the point person for providing the RAC with additional documentation.  The RAC will also ask for information about providers and their NPIs, including any providers who were with the group between October 1, 2007 and now, even if the provider is no longer with you.  Connolly suggests copying the list of providers you supply to the RAC and placing it in the personnel file of the contact person to be reminded of this important responsibility if this person leaves the organization.
  5. Develop a basic tracking system for receipt of letters, and activity for each request.
  6. VISIT YOUR RAC WEBSITE AT LEAST WEEKLY.

I have received lots of questions about what a RAC letter will look like, and the speaker today provided a sliver of information saying that the Region C letters will have the CMS logo at the top of the letter and Connolly’s logo at the bottom of the letter.  Because your practice/entity will be providing the RAC with a contact person’s name, unless things are in total chaos at your place of business, the letters will go to the person you’ve entrusted with this important responsibility.

Here are some other questions and answers from the program today:

Q: Does the RAC pay for the copying/mailing for records?

A: They will pay hospitals, but will not pay physicians for record expense.

Q: If  a claim is refunded to Medicare, must the patient be refunded their portion?

A: Yes.

Q:What determines which region the practice/entity belongs to for RAC?

A: The state that the practice/entity is located in.

Q: Are patients contacted if their claim is audited?

A: They receive a notice if the claim is adjusted in any way.

Q: I heard that there are consultants selling RAC insurance – is that a good idea?

A: There is no such thing as audit insurance, but there is such a thing as appeal insurance.

Q: Will a claim be audited if a practice/entity self-audits, finds an error and corrects it?

A: As long as an amended claim is filed by the provider, RAC will not audit the claim.

Q:Who sets the guidelines for medical necessity?

A: The medical director of the RAC.

Q: Are the number of claims that can be audited in each period counted by transaction lines (5 per CMS form) or by claim/single CMS form?

A: By transaction lines.

Q: Will the RACs extrapolate their findings?

A: The RACs are entitled to extrapolate their findings if they so choose.

Q: Are the RACs paid on a percentage of their findings?

A: Yes, RACs are paid a percentage of both overpayments and underpayments.  The percentage ranges from 9% to 12.50% based on each RAC’s bid.

If this information is new to you, I suggest you click on some of the links provided in this article, start developing your RAC plan, and start educating your providers and staff.  This topic is also a good one for sharing of best practices between local and regional groups.  To get email updates on RAC from CMS, sign-up here. Remember to bookmark your RAC’s website and visit often!

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Basics for Healthcare Managers: Medicare Parts A, B, C & D with 2009 Premiums & Deductibles

With the Centers for Medicare and Medicaid Services (CMS) revealing yesterday what the Medicare premiums and deductibles will be for 2009, it seems like a good time to brush up on Medicare and what choices providers have in enrolling and participating in Medicare.

Medicare is a 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)

TRADITIONAL/ORIGINAL FEE-FOR-SERVICE MEDICARE

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 ,068 deductible for 2009, paid by the beneficiary when admitted as a hospital inpatient, is an increase of from 24 in 2008.   Part A helps cover:

  • inpatient care in hospitals
  • 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 2009: .40/month (no change from 2008.)  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 2009, the Part B deductible will be 5, the same as it was in 2008.  Part B helps cover:

  • doctors’ services and outpatient care
  • some services of physical and occupational therapists
  • some home health care


Medicare Part D
–  Starting January 1, 2006, Medicare prescription drug coverage became available to everyone with Medicare.  In 2008, the deductible is 5, in 2009 it will be 5.

MEDICARE HEALTH PLANS (MEDICARE ADVANTAGE)

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, health maintenance organizations (HMOs) and 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.

 

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 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 Organ. (PPO), or a Health Maintenance Organization 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 Medicare fee schedules 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?  Try CMS or Medicare.

Posted in: Medicare & Reimbursement

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