Transcript Medicare Part A

Day 5
Medicare Claims
Processing, Appeals, Fraud
& Abuse
Review
Medicare

Never intended to pay 100% of health care costs
• There are coverage gaps

For people 65+ and under 65 with a disability

4 parts of Medicare
• Part A: Hospital Insurance
• Part B: Medical Insurance
• Part C: Medicare Advantage Plans
• Part D: Prescription Drug Coverage

Part A & B called Original Medicare
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Medicare Part A
(Hospital Insurance)
 Part A
Covers:
•Inpatient hospital care
•Care in a skilled nursing facility (SNF)
•Home health care
•Hospice care
•Blood
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Skilled Nursing Facility (SNF)
Coverage
 Must be a Medicare participating facility
 Physician must certify that patients needs and receives
daily skilled care from RN or therapist
 Prior in-patient hospital stay of 3 days or more (72 hours
as an admitted patient)
• An overnight stay doesn’t always mean an in-patient
day (can be observation day)
• Break in skilled care that lasts more than 30 days will
require a new 3 day hospital stay to qualify for
additional SNF care
 Admitted to SNF within 30 days of discharge from hospital
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Medicare Part B
(Medical Insurance)

Physicians’ Services

Out-patient hospital services

Durable medical equipment

Prosthetics, orthotics, and supplies

Ambulance

Home health care (if not Part A)

Blood (if not Part A)
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Medicare Part B:
Important Terms





Medicare approved amount: Fee Medicare sets for
Medicare covered service
Excess charges: Amount owed by beneficiary above the
Medicare approved amount. In other states, there is a
limit on excess charges of 15%
Ban on Balanced Billing: Massachusetts has a law
prohibiting excess charges by physicians
Accepting Assignment: Accepting the Medicare approved
amount as payment in full
Participating Provider: Signing an agreement saying you
agree to accept assignment for all beneficiaries in all cases
(non-participating – less important in MA)
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Examples of Gaps in Medicare

Part A gaps:
• In-patient hospital deductible
• Daily co-payment for in-patient hospital days 61-90
• Daily co-payment for in-patient hospital days 91-150
• Daily co-payment for SNF days 21-100

Part B gaps:
• Annual deductible
• Co-insurance (usually 20%)

First three pints of blood

Coverage outside the United States
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Medicare Advantage


Alternative option to Original Medicare
• Offered by a private company that contracts with
Medicare to provide a beneficiary with their Part A & B
benefits
The plan must offer Part D drug coverage – members who
want drug coverage may only take drug plan offered by the
Medicare Advantage plan
• If enroll in a stand alone PDP, will be dis-enrolled from Part
C and returned to Original Medicare

Different plan types available
• HMO, HMO-POS, PPO, SNP, PFFS

Automatic disenrollment when changing MA plans
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Quick Reference:
Pro’s of Medicare Advantage Plans
 Medicare Advantage Plans tend to attract people who are not
high utilizers of medical services. They also attract people who
want a lower premium plan
 Pro’s:
• Convenience of having only one plan (drug plan can be
included)
• More choices available (HMO’s, PPO’s…)
• Lower premiums than Medigap plans
• Potential for better coordination of care (HMO’s provide this)
• Additional benefits such as hearing, dental, vision and annual
exams
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Medigap

Option for supplementing Original Medicare
• Offers coverage to fill gaps in Original Medicare
• Offered by private insurance companies, not the federal
government
• Prescription coverage NOT included; if a beneficiary wants
prescription drug coverage, she/he must join a Medicare
Prescription Drug Plan

Must call plan to dis-enroll when changing Medigap plans
• Not automatic disenrollment like with Medicare
Advantage
• Medigap= Private companies that don’t communicate
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Quick Reference:
Pro’s of Medigap Policies

Medigap policies tend to be bought by people with a high utilization of
medical services such as doctors and hospital services. These policies are
also popular amongst individuals who travel in foreign countries and who
like to be able to choose which doctor they see without a referral

Pro’s:
• Can see any provider that accepts Medicare (no networks)
• No referrals or PCP is needed
• Continuous open enrollment periods
• Low to no co-pays or deductibles
• Many policies offer travel coverage
• All policies standard; only 2 types of policies so choosing policy is easier
• ESRD 65+ can join a Medigap policy
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Part D
 Must have Part A and/or Part B to be eligible
 2 ways to get prescription coverage:
1. Medicare Prescription Drug Plans (PDPs); also known as
stand alone plans
2. Medicare Advantage (Part C) Plans with drug coverage
(MA-PD’s)
 Part D is voluntary, but eligible beneficiaries who do not
enroll may be subject to a penalty
•
Must have “creditable coverage” to avoid penalty
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Part D

Plans can differ on many levels but must meet both pharmacy access and
formulary standards set by CMS

Formulary= List of “covered drugs” in the prescription benefit
• Each plan must include and cover certain drugs or certain classes of
drugs

4 Enrollment Periods
•
•
•
•
Initial: Same as Part B (7 months around birthday)
Open: Oct 15th- Dec 7th, coverage effective Jan 1st
Special: Various qualifying events
MADP: Jan 1st - Feb 14th during which beneficiary can:
 Dis-enroll from MA plan and return to original Medicare and enroll in a
stand-alone Medicare Prescription Drug Plan (PDP)
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 Dis-enroll from MA plan without drug coverage and enroll in a PDP
Extra Help

Federal assistance program to help low-income and low-asset
Medicare beneficiaries with costs related to Medicare Part D

Extra Help subsidizes:
• Premiums
• Deductibles
• Copayments
• Coverage Gap “Donut Hole”
• Late Enrollment Penalty

Does NOT subsidize non-formulary or excluded medications

Apply through Social Security Administration
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Extra Help

Full Extra Help
• 135% of the Federal Poverty Level (FPL) and asset limits
• Full premium assistance with no deductible
• Low, capped co-payments. Could be $0 for some
generics at any level
 Partial Extra Help
•
•
•
150% of the FPL and asset limits
Reduced premiums (sliding scale – between 25% -75%
assistance dependent upon income)
Reduced deductible and 15% copayments
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Prescription Advantage

Massachusetts’ State Pharmacy Assistance Program (SPAP)

Provides secondary coverage for those with Medicare or other
“creditable” drug coverage (i.e. retiree plan)

Provides primary prescription coverage for those who don’t
qualify for Medicare

Benefits are based on a sliding income scale only– no asset limit!

Level of assistance provided is determined by gross income

Different income limits for under 65 and 65 and over

Members are provided a SEP (one extra time each year outside
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of open enrollment to enroll or switch plans)
Medicare Claims
Processing, Appeals,
Fraud & Abuse
Claims Processing

Medicare processes over 3 million claims daily for over 39
million beneficiaries

Providers required to process claims directly to Medicare
• Medicare pays for services under the Prospective Payment
System where providers are paid a fixed amount based on
payment categories

Medicare Administrative Contractors (MAC’s)
• Private companies that contract with Medicare to process
Part A & B claims, investigate fraud & abuse, mail
Medicare Summary Notices, provide beneficiary
customary services
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Medicare Summary Notice
(MSN)


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Medicare beneficiaries will receive a Medicare Summary Notice
(MSN) on a quarterly basis
• This is a statement, not a bill
The MSN details:
• Part A and Part B inpatient and outpatient claims processed
during the period
• Dates of service
• Amount billed and paid to the provider and other vital
information
Beneficiaries shouldn’t pay providers until MSN is received to
match provider bill with beneficiary’s record
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Medicare Approved Amount

Medicare decides amount is reasonable for a
particular covered service

Adjusted geographically

These are paid after the A & B deductibles are met

Medicare Part B pays 80% of the Medicare approved
amount for most services after the beneficiary has
met the annual deductible
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Non-participating Providers


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Providers can opt to accept assignment or not accept on a
case-by-case decision
Medicare only pays for durable medical equipment (DME)
purchased from a participating provider
If provider does not accept assignment:
• Provider is not accepting the Medicare approved amount
• Beneficiary may be required to pay up front and file a
claim with Medicare or other insurers
• Beneficiary must pay the difference between retail price
and Medicare approved amount
• Provider must still bill Medicare
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Medicare and MassHealth

Doctors and most providers must accept
assignment for beneficiaries who are on
MassHealth AND Medicare
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Limiting Charge

Non-participating doctors can charge up to
115% of the Medicare approved amount

Does NOT apply to Durable Medical
Equipment

DOES NOT APPLY IN MASSACHUSETTS
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Massachusetts Ban On Balance
Billing Law

Prohibits doctors licensed in Massachusetts from billing
Medicare beneficiaries for more than the Medicare approved
amount
• Applies only to services provided in Massachusetts

Massachusetts doctors who are “non-participating providers”
and work in other states may charge a patient up to 15%
above the Medicare approved amount
• These are called legitimate excess charges

Some other states that limit Medicare charges include
Connecticut, Rhode Island, Vermont and New York
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Billing Medicare

Federal Law mandates all providers (participating
and non-participating) who furnish services and
products to Medicare beneficiaries submit claims to
Medicare

Also applies to beneficiaries who pay up front
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Crossover Billing

Participating providers, Medicare contractors, Medigap
insurers and most other private insurers participate in
crossover billing for Medicare beneficiaries who assign both
Medicare and Medigap payments to their providers

After the Medicare portion of the claim has been processed,
Medicare forwards the balance of the claim to the Medigap
insurer or other insurer for payment of covered amounts

For crossover to work, the Medicare beneficiary must provide
complete and accurate information to all their Medicare
providers about their other health insurance coverage,
including their Medigap policy
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Medicare as Secondary Payer

Medicare is the primary payer for most beneficiaries with
Medicare supplement insurance policies

In general, Medicare is the secondary payer for Medicare
covered services if the beneficiary is also covered by any of
the following:
• Motor vehicle or liability insurance
• Employer group insurance
• Public Health Service
• Indian Health Service
• Workers’ Compensation
• Black Lung Program
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Medicare Patient Rights
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The right to receive easy-to-understand information about
Medicare including info on costs, payments, how to file an appeal
The right to file appeals and grievances
The right to know all treatment options from the health care
provider in language that is understandable and clear to the
beneficiary
The right to emergency care without prior approval anywhere in
the United States
The right to have personal information that Medicare collects kept
private
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Medicare Fraud & Abuse

Fraud
• The intentional
deception or misrepresentation that an
individual makes knowing that it could result in an
unauthorized benefit

Abuse
• The unintentional practice or procedure inconsistent with
sound medical, business or fiscal practice resulting in a
provider receiving payment that fail to meet recognized
standards of care or incur unnecessary costs

Where to report suspected fraud:
•
•
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1-800-MEDICARE or the Inspector General’s Hotline (800-447-8477)
Medicaid fraud: Office of the Attorney General, Medicaid Fraud
Control Unit (617-727-2200 x3404)
Part C or Part D fraud: SafeGuard Services (877-772-3379)
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Utilization Review Committee (URC)

The URC continually reviews patients’ stays in hospitals and skilled
nursing facilities

URC works within facilities and is comprised of doctors or
professionals not related to the patients involved

Each admitted person’s doctor must satisfy the URC that the
patient meets the admission criteria and continues to need an
acute hospital level of care

A URC has the authority to terminate Medicare’s obligation to pay
for medical services in a hospital or skilled nursing facility
• It is the URC that determines that it’s time to be discharged
• If a patient disagrees, s/he may appeal
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Hospital/Skilled Nursing Facility
Discharge Patient Rights

Hospitals are required to deliver the Important Message from
Medicare (IM), to all Medicare beneficiaries (Original
Medicare & MA beneficiaries) who are hospital inpatients
which informs them of their hospital discharge appeal rights

To appeal a proposed discharge, beneficiary should call
MassPRO and request an immediate review of the notice
• MassPRO is the Quality Improvement Organization [QIO];
an organization of doctors and nurses who contract with
Medicare to review hospital discharge decisions
• The MassPro helpline is available 24 hours a day, 7 days a
week, including holidays
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Discharge Patient Rights, cont.

Once Masspro receives the request, they will review the
appeal within 24 hours of receiving the medical record
• Masspro informs the beneficiary and the healthcare provider of
the decision first by phone, then by letter and also provides
information about additional appeal rights

If the beneficiary believes they are being made to leave the
hospital too soon and they call Mass-Pro within the required
time-frame, the hospital may NOT discharge the beneficiary
until Mass-Pro has completed its review

Patient liability begins the day following the Masspro decision
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Where to go for Help:
Appeals & Grievances

MAP (Massachusetts Medicare Advocacy Project)
• Provides free advice and legal representation for
Massachusetts Medicare beneficiaries
• (866) 778-0939 or (800) 323-3205

MassPro (Massachusetts Peer Review Organization)
• Group of practicing doctors and other health care
professionals paid by the federal government to review and
monitor quality of care given to Medicare beneficiaries
• Processes quality of care complaints and grievances and
some hospital appeals
• (800) 252-5533; www.masspro.org
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Review
1.
What is a Medicare Summary Notice?
2.
Providers can opt to accept/not accept assignment on a
case-by-case decision
True
False
3.
What are some Medicare Patient Rights?
4.
What is the difference between Medicare fraud and
Medicare abuse?
5.
Who provides free advice and legal representation for
Massachusetts Medicare beneficiaries?
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Case Study 1:
Mr. Felix DeKatt

Felix has diabetes and has been seeing a podiatrist
for the past three months for foot care. Recently
Felix changed doctors and was asked to pay $75 for
the office visit. Felix was sure that Medicare paid for
these services since he had never received a bill from
his previous podiatrist. When Felix questioned the
billing clerk in the doctor’s office, he was told that
Medicare does not cover routine foot care.
• How would you help him?
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Case Study 2:
Cal Asthenik

Cal was having a hard time walking. He received a
call from a company that sells wheelchairs. He
ordered a wheelchair after the salesperson assured
him that Medicare would reimburse him for the
expense. He was surprised to find that Medicare
would not pay for it. What would you tell him about
the procedure for getting a wheelchair under
Medicare?
• How would you help him with this situation?
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Case Study 3:
Fran Tikk

Fran is 71 and on a federal employee group retiree plan with Blue
Cross/Blue Shield (BCBS) for which she is paying a premium of over
$150/mth. She has had many health problems recently, and her plan
doesn’t provide full coverage. When she turned 65 in 2005, she called
Social Security (SS) to see about enrolling in Medicare. She was told she was
not eligible for Medicare because she hadn’t worked under SS. In 2007 a
rep at her BCBS plan told her she would be eligible for Medicare under her
ex-spouse who had worked under SS. (They had been married for more than 10
years.) The SS worker confirmed that she was eligible under her former
spouse but would face a penalty for not signing up back in 2005. Fran
refused Medicare at that point because she could not afford it with the
penalty. (Goss income less than $1000/month, with few savings). Fran was told
by the rep at BCBS that if she could get Medicare A&B, her BCBS would act
as a supplement providing full coverage at a lower cost. She could drop38
down to a plan that would cost far less than what she is currently paying.
Case Study 4:
Jack R. Abbot

Mr Abbot is retired and having problems with his
insurance covering his medical bills. He keeps getting
denial notices for many of the services he receives.
He wants to meet with you to get some help with
resolving the situation.
• What information would you ask Mr. Abbot to
bring to your meeting?
• How would you help him?
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Case Study 5:
Mr. Perry Scope

Mr. Scope fell and broke his hip. Since his
discharge from the hospital he has been
receiving physical therapy services in his
home. He was told by his physical therapist,
however, that the therapy will end next week.
Mr. Scope thinks that he needs more therapy.
• How would you help him?
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Case Study 6:
Barbie Que

Barbie calls you at the SHINE office. She tells you she has
been covered under Blue Cross/Blue Shield’s Medex Gold
plan because she takes a lot of medications. She is very
satisfied with the Gold plan but is finding it difficult to pay the
premium on top of the expenses she has maintaining her
home. Barbie looked into the program through Social Security
that helps pay for prescription costs, but tells you her
monthly income of $1,725 and assets of $40,000 make her
ineligible.
• How would you help her?
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Case Study 7:
Al Falfa

Al meets with you at the SHINE office. He will be 65 next
month and is retiring. He has just returned from Social
Security and will receive Medicare A and B. His neighbor has a
Medigap Supplement 1 plan, so he also signed up effective on
the first of next month when his Medicare begins. He has
three prescriptions: one is a brand, Advair, and the other two
are generics. He has heard negative things about Part D, so he
tells you he may just pay for his prescriptions out of pocket.
His only income will be $11,900/year from Social Security, and
he currently has $8000 in the bank.
• How would you help him?
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Case Study 8:
Jen Teal

Jen joined a Part D plan last year but wants to find out if there is a
better plan she can join this year. She takes a few expensive
brands which she paid for in full during the donut hole at a cost of
several hundred per month. A friend told her she should have
signed up for the plan that covers brands during the donut hole,
so she wants to know if that’s what she should do this year. Her
only income is SS of $1,450 per month, she has assets that make
her ineligible for benefit programs. She lives in her own home
and wants to stay there for as long as she can afford to. Although
her assets prevent her from getting any assistance, she uses her
assets to help with her prescription costs and to maintain her
home.
• How would you help her?
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Quiz
1. While driving to work Josephine has a minor traffic accident.
As a precaution she was transported to the hospital in an
ambulance and was examined by a physician in the ER.
Josephine gave the emergency room clerk her Medicare and
Medigap insurance information. Several weeks later Josephine
received a denial from Medicare for the services. Who pays
first?
a) Insurance b)Health Plan
c) Medicare d) Employer Health Plan
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Quiz, cont.
2. Harriet has been in the hospital for 4 days recovering from gall
bladder surgery. The hospital staff has informed her that she is
being discharged the following day. Harriet does not feel strong
enough to return home and wants to appeal this discharge. To
whom should she direct her appeal?
a) Medicare Advocacy Project b) Medicare Part B
c) Mass PRO
d) Surgeon General
3. What are the guidelines for an Expedited Appeal?
4. Mary Jones bas been receiving home health services for the past
6 weeks. She calls you because the home health agency informed
her today that she will be discharged from receiving these
services next week. Mary feels she still needs physical therapy.
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How would you help her?