Day 5 Medicare Claims Processing, Appeals, Fraud

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Day 5Medicare Claims Processing, Appeals, Fraud
Abuse
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Review
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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 doesnt 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 ReferencePros 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
• Pros
• Convenience of having only one plan (drug plan
  can be included)
• More choices available (HMOs, PPOs)
• Lower premiums than Medigap plans
• Potential for better coordination of care (HMOs
  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 dont communicate

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Quick ReferencePros 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
• Pros
• 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-PDs)
• 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)
• Dis-enroll from MA plan without drug coverage
  and enroll in a PDP

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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 dont 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 of open enrollment to enroll or
  switch plans)

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Medicare Claims Processing, Appeals, Fraud Abuse
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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 (MACs)
• 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)

• 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 shouldnt pay providers until MSN
  is received to match provider bill with
  beneficiarys 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

• 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

• 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
• 1-800-MEDICARE or the Inspector Generals 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 persons 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 Medicares
  obligation to pay for medical services in a
  hospital or skilled nursing facility
• It is the URC that determines that its 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
• [phone] or [phone]
• 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
• [phone] www.masspro.org

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Review

• What is a Medicare Summary Notice?
• Providers can opt to accept/not accept assignment
  on a case-by-case decision
• True False
• What are some Medicare Patient Rights?
• What is the difference between Medicare fraud and
  Medicare abuse?
• Who provides free advice and legal representation
  for Massachusetts Medicare beneficiaries?

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Case Study 1Mr. 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 doctors office, he was told that
  Medicare does not cover routine foot care.
• How would you help him?

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Case Study 2Cal 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 3Fran 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 doesnt 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 hadnt 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 AB, her BCBS would act as a
  supplement providing full coverage at a lower
  cost. She could drop down to a plan that would
  cost far less than what she is currently paying.

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Case Study 4Jack 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 5Mr. 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 6Barbie Que

• Barbie calls you at the SHINE office. She tells
  you she has been covered under Blue Cross/Blue
  Shields 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 7Al 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 8Jen 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 thats 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

• 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?
• Insurance b)Health Plan
• c) Medicare d) Employer Health Plan

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Quiz, cont.

• 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
• What are the guidelines for an Expedited Appeal?
• 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. How would you help her?