Combo with Chapters 9-12 TriCare and CHAMPVA and 3 others

government health program serving dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members.

Civilian Health and Medical program of the Uniformed Services (CHAMPUS)
TRICARE replaced this program. TRICARE is a regionally managed health care program serving 9.6 million beneficiaries.

uniformed service member in a family qualified for TRICARE or CHAMPVA

Defense Enrollment Eligibilty Reporting System (DEERS)
worldwide database of TRICARE and CHAMPVA beneficiaries / info. about patient eligibility is stored in DEERS

Who is eligible for TRICARE?
Members of uniformed services & their families: Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Servie and National Ocianic and Atmospheric Administration, Reserve and National Guard personnel.

Who makes decisions about eligibility for TRICARE?
various branches of military service makes them.

Authorized providers are certified by
TRICARE regional contractors… specific educational licensing and other requirements. Once authorized, a provider is assigned a PIN and must decide whether to participate.

Participating Providers
agree to accept the TRICARE allowable charge as payment in full for services.

Participating Providers
– file claims on behalf of patients
– may appeal claim decisions

TRICARE contractor
sends payment directly to the provider, and provider collects patient’s share of the charges.

Nonparticipating Providers
may not charge more than 115 percent of the allowable charge. If provider bills more than 115 %, the patient may refuse to pay the excess amount. The difference would have to be written off by the provider.

coinsurance for a TRICARE or CHAMPVA beneficiary; The amount that is the responsibility of the patient. (either 20 or 25 percent)

Nonparticipating Provider Payments
NonPAR provider submits claim, TRICARE pays its portion and payment is mailed to the patient (instead of directly to provider) Then patient makes payment to provider.

providers who participate in basic TRICARE plan are paid the amount specified in the Medicare Fee Schedule.

TRICARE maximum Allowable Charge (TMAC)
maximum amount TRICARE will pay for a procedure; PROVIDERS are responsible for collecting patients’ deductibles & cost-share portions of the charges.

Network Providers
Participating providers may choose to become part of TRICARE Network; They see patients in one of TRICARE’s managed care plans and agree to provide care to beneficiaries at contracted rates & to act as participating providers on all TRICARE claims.

fee-for-service health plan; replaces CHAMPUS program.

TRICARE Standard
covers medical services provided by a civilian physician or by a Military Treatment Facility (MTF)

Military Treatment Facility (MTF)
provides medical services for members and dependents of the uniformed services. First priority is given to member on active duty

TRICARE Standard
Fee-For-Service Program… Cost-Share
medical expenses are shared between TRICARE and the beneficiary.
Most enrollees pay annual deductibles
families of active-duty members pay 20 percent of outpatient charges.

TRICARE Standard Deductibles / Cost-Share
– Active Duty members pay 20% of outpatient charges
– Retirees/families, former spouses, families of deceased pay 25% cost-share for outpatient services.

Annual Catastrophic Cap
Maximum annual amount a TRICARE beneficiary must pay for deductible and cost share. Once met TRICARE pays 100%

Active-Duty Families annual Catastrophic Cap

All other beneficiaries’ Annual Catastrophic Cap

TRICARE Non-Covered Services
Cosmetic drigs and cosmetic surgery
Custodial Care
Unproven (experimental) procedures or treatments
Routine physical examinations or foot care (!?)

Catchment Area
geographic area served by a hospital, clinic, or dental clinic; TRICARE encourages individuals to first go for care at a military treatment facility (MTF) if in catchment area

Nonavailability Statement (NAS)
an electronic document stating that the required service is not available at the nearby military treatment facility.; Form is required if TRICARE member seeks medical services outside an MTF

Medical information specialists should contact the TRICARE contractor for specific information

basic managed care health plan / similar to an HMO(4 different kinds)
All active-duty svc members are automatically enrolled in TRICARE Prime, and do not have the option of choosing from among additional TRICARE options.

Primary Care Manager (PCM)
provider who coordinates and manages the care of TRICARE beneficiaries; used only in TRICARE Prime

Offers most of TRICARE Standard benefits AND preventitive care.. including routine examinations.

TRICARE Prime Remote
provides no-cost health care through civilian providers for service members and their families who are on remote assignment. must be 50+ miles from home.

alternative managed care plan for those who want services primarily from civilian facilities; a MCP that offers a network of civilian providers.
– More expensive than TRICARE Prime/ Less costly than TRICARE Standard.

TRICARE Reserve Select (TRS)
a premium-based health plan available for purchase by certian members of the National Guard and Reserve activated on 9/11/01.

TRICARE is a Secondary Payer
If individual has other health insurance coverage primary to TRICARE it must be billed first. TRICARE is a secondary payer with the exception of Medicaid, which always pays last. (if supplemental ins. is owned, TRICARE is primary payer)

TRICARE for Life
program for Medicare-eligible military retirees and Medicare-eligible family members. Offers opportunity to receive health care at military treatment facility to individuals age 65+ for those eligible for both.

TRICARE for Life
In the past, individuals became ineligible for TRICARE once they reached 65, and were required to enroll in Medicare to obtain any health care coverage.

TRICARE for Life
Acts as a secondary payer to Medicare; medicare pays first, and TRICARE pays the remaining out-of-pocket expenses. Claims are filed automatically; Medicare pays and forwards claim to WPS/TFL.

TRICARE for Life
-Benefits similar to Medicare HMO;
-Indiv. already enrolled in Medicare HMO may not participate in TRICARE for Life;

TRICARE for Life enrollees…
must be enrolled in Medicare Parts A & B and must have Part B premiums deducted from their Soc. Sec. check.

CHAMPVA Civilian health and Medical Program of the Department of Veterans Affairs
government’s health insurance program for veterans with 100 percent service-related disabilities and their families

Civilian Health and medical Program of the Department of Veterans Affairs

Health care expenses are shared between the Department of Veterans Affairs (VA) and the beneficiary.

CHAMPVA Eligibility
– Veterans who are totally and permanently disabled due to service-connected injuries.
– Dependents of a veteran who was totally and permanently disabled due to a service-connected condition at the time of death.
– Survivors of a veteran who died as a result of a service-related disability
– Survivors of a veteran who died in the line of duty
includes spouses or unmarried children

CHAMPVA Authorization Card – each eligible beneficiary possesses one.

CHAMPVA Covered Services
most medically necessary services are covered.
Include Inpatient Services (hospital) and Outpatient Services (maternity, Family planning, cancer screenings, cholesterol, HIV testing, Immunizations, Well-check to 6 yr, DME, Mental health care, Ambulance services, diagnostic tests, hospice)

CHAMPVA Excluded Services
medically unnecessary services and supplies
Experimental or investigational procedures
Custodial care
Dental care

Preauthorization for CHAMPVA
Patient’s responsibility, not provider’s to provide preauthorization.

Participating CHAMPVA Providers
For most services, CHAMPVA does not contract with providers. Beneficiaries may receive care from providers of their choice as long as those providers are properly licensed and not on Medicare exclusion list.

Participating CHAMPVA Providers
are prohibited from charging more than the allowable CHAMPVA amounts, and agree to accept CHAMPVA payment and the patient’s cost-share payment as payment in full

Procedures that require CHAMPVA authorization
Mental health & substance abuse services
Organ and bone marrow transplants
Dental care
Hospice sercies
Durable medical equipment in excess of $300

-most persons enrolled pay an annual deductible and a portion of their helath care charges.
– out-of-pocket costs subject to a catastrophie cap of $3,000/calendar yr. (then CHAMPVA pays 100%)

CHAMPVA Maximum Allowable Charge (CMAC)
Maximum amount CHAMPVA will pay for a procedure.

More CHAMPVA Costs
-CHAMPVA has $50 deductible per person up to $100 per family per clendar year
-cost-share of 25 percent (75 for CHAMPVA / 25 for indiv)
– Beneficiary is responsible for costs not covered by CHAMPVA

CHAMPVA is almost always secondary payer except when…
-a person has Medicaid and
-Supplemental policies purchased to cover deductibles, cost shares and other services.

CHAMPVA for Life
extends CHAMPVA benefits to spouses or dependents who are age 65 and over….
– CHAMPVA for Life benefits are payable after payment by Medicare or other third-party payers.
-Eligible beneficiaries must be 65+ & enrolled in Medicare Parts A & B; CHAMPVA acts as primary payer

Three administration regions for TRICARE
Plus another region for International Claims

Filing TRICARE Claims…. Nonparticipating Provider
Individuals file their own claims when services are received from nonparticipating providers;

Filing TRICARE Claim from participating provider
Participating providers file claims on behalf of patients
Claims are submitted to regional contractor based on the patient’s home address

Military health System (MHS) and TRICARE health plan
are required to comply with the HIPAA Privacy policy and procedures for use and disclosure of PHI.

TRICARE Claim Filing Deadline
Claims must be filed within one year of the date the servcie was provided.

Program Integrity Office
Oversees the fraud & abuse program for TRICARE; working with Office of Inspector General Defense Criminal Investigative Service (DCIS) to identify and prosecute cases.

Filing CHAMPVA Claims
CHAMPVA program is covered by HIPAA regulations and most CHAMPVA claims are filed by providers and submitted to the centralized CHAMPVA claims processing center in Denver, CO.

CHAMPVA Claim Form
VA Form 10-7959A; must always be accompanied by an itemized bill from the provider.
Must be filed within 1 year of date of service or discharge.

Federal Medicaid Assistance Percentage (FMAP)
basis for federal government Medicaid allocations to states; Federal Government makes payments to states, amt is based on State’s per capita income

Federal Medicaid Assistance Percentage

Categorically Needy
person who receives assistance from government programs

Temporary Assistance for Needy Families (TANF)
program that provides cash assistance for low-income families; eligibility is determined at county level

Temporary Assistance for Needy Families

State Children’s Health Insurance Program (SCHIP)
offers health insurance coverage for uninsured children

State Children’s Health Insurance Program

Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
Medicaid’s prevention, early detection, and treatment program for eligible children under twenty-one

Early and Periodic Screening, Diagnosis, and Treatment

Welfare Reform Act
law that established TANF and tightened Medicaid eligibility requirements

Medically Needy
classification for people with high medical expenses and low financial resources

California’s Medicaid program; States choose their own name for their Assistance program

state-based Medicaid program requiring beneficiaries to pay part of their monthly medical expenses; Individuals are required to spend portion of their income or resources on health care until they reach / or drop below the income level specified by the state. Varies upon individual’s financial resources.

Medicaid Enrollment Verification – Cards / Coupons
depending upon state are issued
2x/month; 1x/month; every 2 months; or every 6 months

Medicaid Program – established under title XIX of SS Act of 1965
helps pay for health care needs of individuals and families with low incomes and few resources.

Medicaid Program
covers nearly 50 million low-income people; is financed by the Federal Government and the States; cost exceeds $300 billion/yr.

Medicaid Coverage
must meet minimum federal requirements and state’s requirements; person eligible in 1 state may not be covered in another state. Amount of state coverage also varies.

To apply for Medicaid:
contact local Income Maintenance office or Dept. of Social Services request application.

Eligibility – must be categorically needy – Federal Gov’t requires states to offer benefits to:
– People recv’g TANF
– those eligible but don’t receive TANF
– Those receiving Foster care or adoption assistance under SS Act
– Children undr 6 yrs of age from low-income families
– Some people who lose cash assistance when their work income or SS benefits exceed allowable limits
– Infants born to Medicaid-eligible pregnant women
– People 65+, legally blind or disabled who receive SSI
– Certain low-income Medicare recipients

SCHIP – State Children’s Health Insurance Prog.
Covers children under 19 in families whose incomes are not low enough to qualify for Medicaid.
Funded by Fedl. Govt. and the states.
Provides coverage for preventive svcs., phys. svcs, inpatient & outpatient svcs.

EPSDT – Early and Periodic Screening, Diagnosis, and Treatment
Health care benefits to Medicaid children under 21.
1. Medical History (physical & mental)
2. physical exam
3. immunizations
4. Lab tests
5. Health education
6. Vision
7. Dental
8. hearing
9. Other necessary services

Ticket to Work and Work Incentives Improvement Act (TWWIIA)
expands availability of health care services for workers with diabilities. Allows those with disabilities to gain employment

New Freedom Initiative of 2001
For those with illness and long-term disabilities; mandates states provide necessary supports to allow elders and disabled to participate in community life; i.e… at-home community living instead of nursing homes

Spousal Impoverishment Protection (Federal)
limits amount of a married couples’ income & assets that must be used before one of them can become eligible for Medicaid coverage in a long-tem care facility. All assets are checked

Wlfare Reform Act (or Personal Responsibility and Work Opportunity Reconciliation Act of 1996)
Law that established TANF and tightened Medicaid eligibilty requirements.

ADFC- Aid to families w/ Dependent Children
Replaced by TANF (Temporary Assistance for Needy Families) by the Welfare Reform Act. Some receive TANF for max of 5 yrs.

Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009
requthorized the State Children’s health Insurance Program (SCHIP). It emphsizes preventive coverage.

State Programs
States estabilish their own eligibility standards; type, amount, duration etc..; income relative to Fed. Poverty level; also whether person is Medically Needy.
Income & Asset Guidelines
Spend Down Programs

Income & Asset Guidelines
Determined by the state; cash, stocks, bonds, CDs, bank accounts;

Not included in Assets
residence; clothing, furniture, burial plot, personal effects;

Applicants who enter long-term care facility
have their homes counted as assets

Spend Down programs
state based, requires individuals to spend a portion of their income on health care until they reach or drop below the income level specified by the state; similar to annual deductible, but it resets at 1st of every month. i.e. monthly spend down level could be $100 of health care bills, after $100 is paid, Medicaid will pick up rest for that month.

Medicaid Enrollment Verification
cards or coupons issued to qualified individuals.
Insurance procedures
Medicaid Fraud and Abuse

Insurance procedures
patient’s eligibility dates should be checked each time they make an appointment and before they see the physician.

Electronic Medicaid Eligibility Verification System – most states use this to check patient’s eligibility.

Restricted status
The patient is required to see a specific physician and /or use a specific pharmacy. This info is listed on their ID card. If patient uses diff’t services, Medicaid benefits will be denied

Medicare Integrity Program (MIP)
created by the Deficit Reduction Act of 2005 to prevent and reduce fraud, waste, and abuse in Medicaid. States can enact their own False Claims Acts under this law.

Covered Services
To receive federal matching funds, state must cover certian services, including: see pg. 441

Excluded Services
vary from state to state… these may not be covered:
– not medically necessary services
– Experimental or investigational procedures
– cosmetic procedures

Plans and Payments
In most states, Medicaid offers both fee-for-service and managed care plans

Medicaid clients enrolled in FFS plan may be treated by the provider of their choice as long as that provider accepts Medicaid. Provider’s claim is paid directly by Medicaid

Managed care
Patient must choose from a network of providers, hospitals, clinics. All services require a referral from a PCP, primary care physician

Medicaid Managed Care Claimsq
Filed differently than other Medicaid claims. claims are sent to the managed care organization instead of to the state Medicaid department.

Payment for Services
A physician who wishes to provide services to Medicaid recipients must sign a contract with the Dept. of Health and Human Services (HHS).

Physicians who sign contracts to treat Medicaid patients must agree to:
– accept payment from Medicaid as payment in full
– they may not bill patients for additional amounts
– difference must be entered into system as write-off
– amt. is determined by HHS & XIX of SS Act

Cost-share payments
small patient payments required by states in form of deductible, coinsurance or copayments.

medicare postpayment review information
PCP’s name
PCP’s Medicaid PIN
Date PCP contracted the referring provider
Reason for referral
Patient’s name
Patient’s Medicaid ID number
Patient’s date of birth

Third-Party Liability
Before filing a claim w/ Medicaid, determine whether patient has other insurance coverage.
payer of Last Resort
Medicare-Medicaid Crossover Claims

Payer of Last Resort
If patient has any other insurance plan or if claim is covered by another program, they are billed before Medicaid. Medicad pays last on a claim

Medicare-Medicaid Crossover Claims
Patients who are eligible for Medicare and Medicaid; Medicare claim submitted first, then automatically submitted to Medicaid for coverage…

Medi-Medi beneficiaries
patients eligible for both Medicare and Medicaid

Dual Eligible
Medicare-Medicaid beneficiary

Crossover Claim
claim for Medi-Medi beneficiary… submittied first to Medicare and then automatically to Medicaid for coverage.

Maximum Allowed Limit
Total amount paid by Medicare & Medicaid… total amount allowed.

Claim Filing and Completion Guidelines
Where to File
Medicaid Coding
Unacceptable Billing Practices
After Filing
Medicaid claim completion
HIPAA Claims (837 & 835)
CMS-1500 Paper Claims

HIPAA 835 remittance advice
the standard transaction sent by payers to Medicaid providers

used for electronic claims and for coordination of benefits

PHI and Dual-Eligibles
HIPAA Privacy Rule permits sharing of PHI for payment purposes, and allows Medicare plans and state Medicaid agencies to exhange enrollee information

National Medicaid EDI HIPAA Workgroup (NMEH)
A National committee that advises CMS about HIPAA compliance issues related to Medicaid.

Where to File Medicaid Claims
Depends on State; they may use:
– Fiscal Intermediary (private ins. co)
– Department of Health and Human Services
– County welfare agency
Medical offices have specific claim filing & completion requirement forms from agency who processes claims.

Medicaid Coding
Mostly use CPT / HCPCS coding system mandated by HIPAA;
ICD-9-CM is used for diagnoses.

Unacceptable Billing Practices
-Billing Services not medically necessary
-Billing for not provided services, or more than once
-submitting indiv. claims that are part of global procedure
-submitting claim for indiv. provider when a group practice or clinic performs services.

After Filing – Actions for Appeal may be taken
Claims that are denied may be appealed withing 30-60 days. Appeals should include:
relevant supporting documentation
note explaining why the claim should be reconsidered

Appeal for Denied Claim
First level of Appeal is Regional Agent for Medicaid – state’s welfaire dept.
Highest level for Medicaid appeal is Appellate court

Medicaid Claim Completion
Medicaid claims are usually submitted
-using HIPAA 837 claim.
-In some situations the paper claim CMS-1500 may be used
-State specific form

Data Elements for HIPAA-compliant Medicaid Claims
– Family Planning Services Indicators
Y= FMP involvement
N = FMP no involvement

EPSDT Indicators
Y = Services are result of screeming referral
N = services are not result of screening referral

Special Program Code
Codes reported for Medicaid beneficiaries

Service Authorization Exception Code
Required when providers are required by state law to obtain authorization for specific services and it was not obtained for reasons like Emergency care situations.

Physician’s Medicaid number
reported as a secondary identifier

Medicare Part A (Hospital Insurance (HI))
program that pays for hospitalization, care in a skilled nursing facility, home health care and hospice care

Medicare Part B (Supplementary Medical Insurance (SMI))
program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.

Medicare Part B (supplementary Medical Insurance)
voluntary program
those desiring it must enroll, coverage is not automatic
Beneficiaries pay a monthy premium based on SS benefit rates.
Subject to annual deductible and coinsurance

Medicare Part B (two types of plans)
1. Original Medicare Plan
2. Medicare Advantage Plans

Spell of Illness / spell of illness benefit period
commences on the first day of the patient’s stay in a hospital or skilled nursing facility and continues until sixty consecutive days have lapsed and the patient has received no skilled care.

The patient benefit with Medicare, the spell of illness,
does not end until 60 days after discharge from the hospital or skilled nursing facility. IF the patient is re-admitted within those 60 days, patient is considered to be within tose same benefit period on not subject to another deductible.

medicare Part C
managed care health plans under the Medicare Advantage program.

Medicare Part C
under part C private health insurance companies contract with CMS to offer Medicare beneficiaries medicare advantange plans that compete with the Original medicare plan.

MMA Medicare Modernization Act of 2003
under the Medicare Prescription Drug, Improvement and Modernization Act, in 2003 Advantage became the new name for Medicar + Choice plans, and certain rules were changed to give part C enrollees better beneifits and lower costs.

Medicare Modernization Act MMA
law with a number of medicare changes, includeing a prescription drug benefit

medicare part D.
medicare prescription drug reimbursement plans

Medicare Part D
Authorized under MMA, provides voluntary Medicare prescription drug plans that are open to people who are eligible for Medicare.

Online Eligibility Data
The healthcare Eligibility Transaction System (HETS) system allows release of elegibility date to Medicare providers

Medicare card
Medicare insurance identification card

Medicare health insurace claim number (HCN)
Medicare beneficiary’s identification number

Common Working File (CWF)
medicare’s master patient-procedure database

fiscal intermediary
government contractor that processes claims

health plan

medicare administrative contractor (MAC)
contractor who handles claims and related functions

Counseling Services
Medicare covers smoking and tobacco-use cessation counseling services

Initial preventive physical examination (IPPE)
benefit of a preventative visit for new beneficiaries

Preventive Services and Deductibles
Under medicare Part B, some preventive services are subject to a deductible, and some are not. The Medicare plan summary grid should note these requirements.

Screening Services
tests or procedures performed for a patient with no symptoms, abnormal findings or relevant history.

Billing for Missed Appointments
PAR providers may bill Medicare beneficiaries for missed appointments as long as they also charge non-Medicare patients the same amount.

Local coverage determination (LCD)
notices sent to physicians with informaion about the coding and medical necessity of a service.

national coverage determination coverage (NCD)
Policy stating whether and under what circumstances a service is covered

Advance Beneficiary Notice of NON coverage from CMS (ABN)
form used to inform patients that a service is not likely to be covered by Medicare and thus not reimbursed;
Must be verbally communicated to beneficiary.
patient must review and sign it.
not required in Emergency situation.

ABN has 5 Sections
1. Header (Blanks A-D)
2. Body (Blanks D-F)
3. Options Box (Blank G)
4.Additional Informaiton (Blank H)
5. Signature Bos (Blanks I-J)

provider who completes the header on an ABN

ABN’s help beneficiary make an informed decision about out-of-pocket services and treatment
Mandatory ABNs
Voluntary ABNs

Voluntary ABN
replaces a formerly used form, the Notice of Exclusions from medicare Benefits (NEMB) for care that is never covered, i.e. personal comfort items; routine physicals & screenings; routine eye care; dental care; foot care

Medicare Participating Providers
– agree to accept assignment for all medicare claims & Medicare’s fee as payment in full for services.
– Responsible for informing patients when services will not, or a re not likely to be, paid by the program
– Must comply with numerous billing rules such as global periods.

Health professional Shortage Area – geographical areaoffering participation bonuses to physicians

ABN Section 1: Header
– shows the provider’s name, address & phone number; may list more than 1 billing entity and contact person.
– Patient Name
– ID Number

ABN Section 2: Body
D. Descriptors (item, service, lab test, procedure, care etc.)
E. Reason Medicare May Not pay (for this test for your condition, denied as too frequent a service, experimental or research use tests)
F. Estimated cost

ABN Section 3: Options Box
This section is to be filled in by the patient, has 3 choices:
1. Receive items/services & requires a claim be submitted
2. receive items/services by paying out of pocket; no claim filed & Medicare not billed
3. Beneficiary opts out of receiving care

May only choose 1 option

ABN Section 4: Additional Information
provider gives additional clarification

ABN Section 5: Signature Box
Done last, signifies beneficiary has reviewed and understands all information in the ABN

ABN Modifiers
Indicate whether an ABN is on file or was condsidered needed

– GY Modifier
Used to speed Medicare denials so amount due can be collected from patient

Limiting Charge
highest fee nonparticipating physicians may charge for a particular service ; they apply only to non participating providers submitting nonassigned claims; May not charge more than 115% OVER the nonPAR fee.

Nonparticipating providers under Medicare
accept 5% less for their services than PAR providers.

Nonparticipating providers are required to:
provide a surgical financial disclosure/advance written notification, when performing elective surgery that is $500+.

Medicare Comprehensive Limiting Charge Compliance Program – created to prevent nonparticipating physicians from collecting the balance from medicare patients.

Different Fee structures for
nonPARs who accept assignment and
nonPARs who do not accept assignment.

Orignal Medicare Plan
a fee-for-service plan that provides maximum freedom of choice when selecting a provider or specialist

Original Medicare plan
allows the beneficiary to choose any licensed physician certified by medicare;
– patients responsible for annual deductible
– coinsurance

(MSN) Medicare Summary Notice
document patients receive that details the services they were provided over a 30-day period; it details their services and charges.

Medicare Advantage Plans/ (Medicare Part C)
group of managed care plans other thatn the Original medicare Plan. It offers 3 major types of plans

Three major tyes of Medicare Advantage Plans
1. Medicare coordinated care plans (CCPs)
2. Medicare private fee-for-service plans
3. Medical Savings Accounts (MSAs) – Medicare health Savings Account program

Medicare Advantantage organization (MAO)
responsible for providing all Medicare-covered services, except hospice care, in returen for a predetermined capitated payments. (may include vision, dental, hearing wellness)

Urgently Needed Care
Beneficiary’s unexpected illness or injury requiring immediate treatment.

Medicare Coordinated Care Plan (CCP)
includes providers who are under contract to deliver the benefit package approved by CMS. Similar to an HMO network of providers.

CCP Plans include the following:
HMOs= most restrictive plans / totally in-network
POS = Point of Service (independent practices assoc)
PPOs = in network, but may also go out of network
SNPs = special Needs Plans
RFBs = Religious Fraternal Benifits Plans

Medicare Private Fee For Service plan; PFFS
patients receive services from Medicare-approved providers or facilities of their choosing.

Medical Savings Accounts (MSAs)
Medicare health savings account program; high deductible fee-for-service plan with a tax-exempt trust to pay for qualified medical expenses.

Medigap Insurance
Private insurance that beneficiaries may purchase to fill in some of the gaps- unpaid amounts – in Medicare coverage.

Medigap Insurance
– pays for services not covered by medicare
– coverage varies, but all provide coverage for patient deductibles and coinsurance
– Some also cover excluded services such as prescription drugs and limited preventative care.

supplemental Insurance
designed to provide additional coverage for an individual receiving benefits under medicare part B. (i.e. opt for this when retiring from a company) not regulated by CMS

Who maintains lists of medigap companies?
MACs maintains this.

Medicare Billing and Compliance
Complex – flow of claims
– from provider
– to the MAC
– back to provider

Medical Insurance biller must be familiar with rules & regulations for the practice’s:
CCi Edits & Global Surgical Packages
Consultation Codes; Noncompliant billing
Timely Filing
Physician Quality Reporting Initiative (PQRI)
MR – Medical Review Program
RAC program – Recovery Audit Contractor Initiative
Duplicate Claims
Split billing

Medicare as the Secondary Payer
Sometimes medicare pays benefits on a claim only after another primary insurance carrier has processed the claim. Medical Information specialist is responsible for knowing when medicare is the secondary payer.

CCI Edits and Global Surgical packages
Medicare requires CPT/HCPCS coding. CCI is a list of CPT code combinations that, if used, would cause a claim to be rejected….. updated Quarterly

Medicare Physician Fee Schedule (MPFS)
Source for regulations on global (surgical) packages …. similar to CCI for physician visits / procedures
MPFS lists all the CPT/HCPCS codes and includes a column labeled GLOBAL PERIOD containing one of the indicators (000, 010, 090, MMM, XXX, YYY, ZZZ)

Consultation codes; noncompliant billing
In 2010 Medicare stopped paying for all consultation codes from the CPT evaluation and management (E/M) codes.. except for G codes (telehealth consultations)

Timely Filing
Medicare requires claim to be filed no later than within one calendar year after the date of service.

Physician Quality Reporting Initiative (PQRI)
a voluntary quality reporting program established by CMS in which physicians or other professionals collect and report their findings. Goal is to determine best practices, define measures, support involvement and improve systems

PQRI Incentive
all or nothing lump-sum payment of additional 2 percent payment from CMS.

PQRI Claims
are reported on claims even though they have no direct monetary value. They are reported as either $0.00 or $0.01.

Medical Review (MR) Program
Ongoing program in which MACs audit claims to check for inappropriate billing. They use the CERT program, Comprehensive Error Rate Testing
– Probe review- checking 20-40 claims for errors
– Prepayment review – form of probation after errors are found in probe review… teaches correct billing procedure
– Postpayment review – another form of probation instead of prepayment review…. targets overbilling

Recovery Audit Contractor (RAC) Initiative/program
aims to ensure that claims paid by the MACs are correct; Approx 6-10% of all claims are incorrect;
RAC program is in all 50 states

Duplicate Claims
those sent to one or more Medicare contractors from the same provider for the same beneficiary, same service and same date of service.

Split Billing
Medicare considers a covered physician service provided at the same place on the same date as a preventive service to be separate and billable (with a -25 modifier) to show that a significatn, separately identifiable E/M service was provided.

ZPICs Zone Program Integrity Contractors(ZPIC)
new fraud-detecting vendors who are hired by CMs for program integrity oversight for all Medicare-related claims in a jurisdiction.

Quality Improvement Organization (QIO)
group of physicians paid by the government to review the Medicare program

Clinical Laboratory Improvement Amendments (CLIA)
laws establishing standards for laboratory testing

Waived Tests
low-risk laboratory tests physicians perform in their offices

Incident-to services
services of allied health professionals provided under the physician’s direct supervision that may be billed under medicare

Roster Billing
simplified billing for vaccines

Electronic Billing Compliance with HIPAA standards
mandates that electronic billing is mandatory except offices with fewer than 10 full-time employees.

Paper claims slow cash flow because:
– paper claims must be held longer than HIPAA- compliant electronic claims
– Paper claims cannot be paid before the 29th day after receipt of the claim, according to CMS guidelines

Medicare Required Data Elements
Information in the Notes segment
Diagnosis Codes
Assumed Care Date / Relinquished Care Date

administrative services only (ASO) contracts
contract where a third-party administrator or insurer provides administrative services to an employer for a fixed fee per employee.

Group Health Plan Regulation
Employer-sponsored group health plans must follow federal and state laws that mandate coverage of specific benefits or treatments and access to care.

Group Health Plan (GHP)
plan of an employer or employee organization to provide health care to employees, former, employees, or theri families

carve out
part of a standard health plan changed under an employer-sponsored plan

open enrollment period
time when a policyholder selects from offered benefits

Federal Employees Health Benefits (FEHB) program
covers employees of the federal program

document modifying an insurance contract

Private Insurance
– Employer Sponsored medical Insurance (insurance covg. under group health plans)
– Federal Employees Health Benefits Program
– Self-Funded Health Plans
– Individual Health Plans

Employee-Sponsored Health Plans
– Plans are organized by employers to provide health care benefits to employees.
– Insurance coverage is purchased from an insurance carrier or managed care organization
– Group health plans are subject to state laws for coverage and payment.

Self-Funded health plans
– Plans are also organized by employers, but the employers insure the plan’s memebers themselves rather than buying insurance coverage.
– They often hire third-party administrators and have administrative services only contracts for tasks such as subscriber enrollment and claim processing
– Plans are controlled by federal ERISA law rather than by state law.

major features of group health plans
Establish and regulate health plans for employees
– Decide on basic plan coverage and optional riders; eligibility requirements; and premiums and deductibles.
– The federal COBRA and HIPAA laws must be observed by the plans to ensure portability and coverage as required.

Provider payment under Preferred provider organization
Under (PPOs), providers are paid under a discounted fee-for-service structure.

Provider payment under Health Maintenance Organization
Under HMO and point-of-service (POS) plans, the payment may be a salary or capitated rate, depending on the business model.

Provider payment under Indemnity Plans
Indemnity plans basically pay from the physician’s fee schedule.

Three types of funding options for out-of-pocket expenses in CDHP (consumer driven health plans)
FSA flexible savings accounts
HSA Health savings accounts
HRA Health Reimbursement account

HRA Health Reimbursement Account
Health Reimbursement Account – is set up by an employer to give tax-advantaged funds for employees’ expenses.

FSA Flexible Savings Account
FSAs and HSAs both can be funded by employees and employers on a tax-advantaged basis.

HSA Health Savings Account
HSA funds can be rolled over and taken by the individual to another job or into retirement, like an IRA; FSAs do not roll over.

Major Private Payers
Large insurance companies that dominate the national market:
WellPoint, Inc.
UnitedHealth Group
CIGNA Health Care
Kaiser Permanente
Health Net
Humana Inc.

BCBS – Blue Cross Blue Shield Association
BCBS is the national organization of independent companies called member plans that insure more than 100 million people
– BCBS offers the BlueCard program and the Flixible Blue plan

Five main parts of Participation Contract
1. Introductory Section – recitals and definitions
2. Contract purpose and covered medical services
3. Physician’s responsibilities
4. managed care plan obligations
5. Compensation and billing guidelines

Introductory Section
provides the names of the parties to the agreement, contract definitions, and the payer.

Contract Purpose and Covered Medical Services
lists type and purpose of the plan and the medical services it covers for its enrollees.

Physician’s responsibilities
Covers physician’s responsibilities as a participating provider

Managed Care Obiligations
covers the plan’s responsibilities toward the participating provider

Compensation and billing guidelines
includes fees, billing rules, filing deadlines, patients’ financial responsiblities, and corrdination of benefits

Types of Private Payers
1. PPO’ Preferred Provider Organizations
2. In health maintenance organizations (HMO’s) and Point of Service (POS) Plans
3. Indemnity Plans

PPO Preferred provider organizations
Under PPO providers are paid under a discounted fee-for-service structure;

discounted fee-for-service
payment schedule for services based on a reduced percentage of usual charges

In Health maintenance organizations (HMO’s) and point of service (POS) plans
payment may be a salary or capitated rate

Indemnity plans
pay from the physician’s fee schedule; patient is responsible for deductible, copay and coinsurance.

arrangement where a capitated provider prepays an ancilliary (supplemental i.e. diagnostics etc) provider

Episode-of-care (EOC) option
flat payment by a health plan to a provider for a defined set of services

Independent practice association (IPA)
HMO in which physicians are self-employed and provide services to members and nonmembers

Point-of-Service Plans (POS)
Primary and secondary networks are available… HMO is the primary in-network providers and costs; PPOs are out of network providers and costs, but may also use in network providers

IHP Individual Health Plan
medical insurance plan purchased by an individual

Section 125 cafeteria plan
employers’ health plans structured to permit funding of premiums with pretax payroll deductions

waiting period
amount of time that must pass before an employee / dependent may enroll in a health plan

late enrollee
category of enrollment that may have different eligibility

individual deductible
fixed amount that must be met periodically by each individual of an insured / dependent group

family deductible
fixed, periodic amount that must be met by the combined payments of an insured / dependent group before benefits begin

maximum benefit limit
amount an insurer agrees to pay for lifetime covered expenses

tiered network
network system that reimburses more for quality, cost-effective providers

list of plan’s selected drugs and their proper dosages

COBRA – Consolidated Budget Reconcilliation Act
law requiring employers with over twenty employees to allow terminated employees to pay for coverage for eighteen months.

creditable coverage
history of coverage for calculation of COBRA benefits; check past insurance coverage history to ensure that there was no break longer than 63+ days in health insurance coverage.

Look Back
Plans can “look back” into the patient’s medical history for a period of 6 months to find conditions that they will exclude, but they cannot look back for a longer period. Also the preexisting condition limitation cannot last more than twelve months after the effective date of coverage (eighteen months for late enrollees).

Pregnancy and Childbirth Rules
A preexisting condition exclusion can’t be applied to pregnancy or to a newborn, adopted child or child placed for adoption if the child is covered under a group health plan withing thirty days after birth,

equality with medical / surgical benefits

Types of private Payers

discounted fee-for-service
payment schedule for services based on a reduced percentage of usual charges.

Open Panel HMO
any physician who meets the HMO’s standards of care may join the HMO as a provider.

Closed panel HMO
the physicians are either HMO employees or belong to a group that has a contract with the HMO

first dollar coverage
no deductible required an patient do not make out of pocket payments. Now, however, HMO’s do have deductibles.

arrangement where a capitated provider prepays an ancilliary provider

episode of care (EOC) option
flat payment by a health plan to a provider for a defined set of services

IPA -independent (or individual) practice association
HMO in which physicians are self-employed and provide services to members and nonmembers

medical home model
care plans that emphasize primary care with coordinated care involving communications among the patient’s physicians

CDHP Consumer Driven Health Plans
combine 2 components that work together:
1. a high-deductible health plan and
2. one or more tax-preferred savings accounts that the consumer/ policyholder directs.

high-deductible health plan (HDHP)
health plan that combines high-deductible insurance and a funding option to pay for patiens’ out-of-pocket expenses up to the deductible

health reimbursement account (HRA)
consumer-driven health plan funding option where an employer sets aside an annual amount for health care costs

Health savings account (HSA)
consumer-driven health plan funding option under which funds are set aside to pay for certain health care costs.
A savings account created by an individual. The maximum amount that can be saved each yr. is set by the IRS.

Flexible Savings (spending) Account
consumer-driven health plan funding option that has employer and employee contributions. Use it or lose it at the end of the year.

pay-for-performance (P4P)
health plan financial incentives program based on provider performance

BCBS – Blue Cross Blue Shield Association
licensing agency of Blue Cross and Blue Shield plans

periodic verification that a provider or facility meets professional standards

BDBS Participation
participating providers in BCBS plans are often called member physicians

program that provides benefits for subscribers who are away from their local areas

host plan
participating provider’s local Blue Cross and Blue Shield plan

home plan
Blue Cross and blue Shield plan in the subscriber’s community

Flexible Blue
Blue Cross and Blue Shield consumer-driven health plan

Most physicians participate in more than twenty health plans

No copay for preventitive Care
Waiving copays for preventitive services is a leading trend in both CDHP and traditional plans.

Withdrawing from a contract
Most participation contracts require physicians to notify patients if the physicians withdraw from the patients’ managed care organization

utilization review
payer’s process for determining medical necessity

stop-loss provision
protection against large losses or severely adverse claims experience; if monthly capitation rate doesn’t cover # of visits per month provider is protected against loss.

List all NPI’s
The contract should list the NPI’s of all practitioners who will bill under it, not only NPI for the practice itself

When the MPFS is the Base
If a payer’s fee schedule is based on the medicare Physician Fee Schedule, the contract shoud state which year’s MPFS is going to be used.

Interpreting Compensation and Billing Guidelines
– Compiling Billing Data
– Getting Billing Information
– Billing for No-Shows
– Collecting Copayments
– Billing and Surgical procedures

preauthorization for hospital admission or outpatient procedures or surgery

Elective Surgery
nonemergency surgical procedure

Silent PPO’s
MCO that purchases a list of participating providers and pays their enrollees’ claims according to the contract’s fee schedule despite the lack of a contract.
a number of states prohibit silent PPO’s and state insurance commissions in other state may be considering such laws

Increasing Covered Services
Keep a record of services that were not paid over a year’s billing period. This record provides a basis for negotiating a revised contract in order to cover more services.

Prompt-Payment Discount
Payers may offer prompt payment in return for larger-than-contracted fees.

Payment for New Procedures
If payer announces payment policy for a new procedure, it must notify all its PAR practices.

Utilization Review Organization (URO)
organization hired by a payer to evaluate medical necessity

Out-of-Network Preauthorization
many plans require preauth. for out of network services even though they are covered under the plan.

plan summary grid
quick-reference table for health plans
– list key info. about each contracted pland
– provide a shortucut reference for billing & reimbursement process
– include info. about collecting payments at time of service & completing caims

when a physician, at the request of another physician, examines the patient and reports to an opinion to the requestor.

care is transferred to another pysician.

278 Referral and Authorization
The HIPAA 278 Referral and Authorization is the electronic format used to obtain approval for preauthorizations and referrals.

vendor that processes a payer’s out of network claims

monthly enrollment list
document of eligible members of a capitated plan for a monthly period.

HDHP billing
1. group health plan etablishes funding option
2. Patient uses money in account to pay for quilified medical services
3. Total deductible must be met before any benefits are paid by HDHP
4. Once deductible is met, HDHP covers a portion of the benefits

Participation Contract Evaluation Team
Led by a practice manager or by a committee of physicians
– Managed care org’s business history, accreditation standing and licensure status are reviewd

All plans, HMO’s, PPO’s, CDHP’s
pay less than physicians’ fee schedules

Main Parts of Participation Contracts are:
– Introductory Section (recitals and definitions)
– Contract purpose & covered medical service
– Physician’s responsibilitie
– Managed care plan obligations
– Compensation & billing guidelines

Physician’s Responsibilities
– covered services
– acceptance of plan members
– referrals
– preauthorization
– quality assurance/utilization review
– Other provisions – HIPAA privacy policies, plan protocols

270 / 271 HIPAA Elibibility for Benefits Transaction
inquiry from provider (270) / response from payer (271) used to verify benefits

Capitated payment adjustments and claim write-offs
Since providers have already been compensated for encounters/mo. in a captated payment; their patients’ claim encounters are written off or they would receive double payment

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