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Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
CHAPTER 1 REIMBURSEMENT, HIPAA,
AND COMPLIANCE
Slide 2 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Third-Party Reimbursement Issues • Each coding system plays critical role in
reimbursement
• Your job is to _______ payment optimize
Slide 3 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Your Responsibility
• Ensure accurate coding data
• Obtain correct reimbursement for services rendered
• ________ (maximizing) is never appropriate Upcoding
Slide 4 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Population Changing
• Elderly fastest growing patient segment • By 2050, 20% of the population will be 65 or
older • Medicare primarily for elderly
Slide 5 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Medicare—Getting Bigger All the Time! • By 2018, national health care spending
expected to reach $4.4 trillion
• Health care will continue to expand to meet enormous future demands – Job security for coders!
Slide 6 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Basic Structure Medicare
• Medicare program established in 1965 – 2 parts: A and B
• Part _: Hospital insurance
• Part _: Supplemental—nonhospital – Example: Physicians’ services and medical equipment
• Part _: Medicare Advantage, health care options (Added later and formerly termed Medicare + Choice)
• Part _: Prescription drugs
A
B
C
D
Slide 7 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Those Covered
• Originally established for those 65 and over
• Later disabled and permanent renal disease (end-stage or transplant) added
• Persons covered “___________” beneficiaries
Slide 8 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Officiating Office
• ___________________________ ________ (DHHS)
• Delegated to Centers for Medicare and Medicaid Services (CMS) – CMS runs Medicare and Medicaid
– CMS delegates daily operation to Medicare Administrative Contractors (MACs)
– MACs usually insurance companies
Department of Health and Human Services
Slide 9 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Funding for Medicare
• Social Security taxes – Equal match from government
• CMS sends money to MACs
• MACs handles paperwork and pay claims
Slide 10 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Medicare Covers (Part B)
• Beneficiary pays – __% of cost of service
– + annual _________
• Medicare pays – __% covered services
20
deductible
80
Slide 11 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Non-participating QIO Providers • Payment sent to patient
• Non-QIOs receive 5% less than participating QIOs
• Slower claims processing
Slide 12 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Participating QIO Providers
• Signed QIO agreement with MACs
• Agree to accept what MACs pay as payment in full – Accept Assignment
• Block __ on CMS-1500 27
(Cont’d…)
Slide 13 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
(…Cont’d)
• Block 27 on CMS-1500, Accept Assignment
(Paper form) Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.
Slide 14 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Why Be a Participating Provider? • MACs usually do not pay charges provider
submits – Significant decrease
• Participating providers receive _% more than non-participating
5
(Cont’d…)
Slide 15 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
More Good Reasons to Participate: (…Cont’d)
• Check sent directly from MACs to participating provider
• _____ claims processing
• Provider names listed in a _______ – Sent to all _____________
Faster directory
beneficiaries
Slide 16 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Part A, Hospital
• More than 99% of hospital claims submitted electronically
• Hospitals submit paper charges on _____ • Diagnosis codes basis for payment
– MS-DRG (Medicare Severity Diagnosis Related Groups)
• More on this topic in Chapter 31
UB04
(Cont’d…)
Slide 17 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Part A, Covered In-Hospital Expenses (…Cont’d)
• Semiprivate room
• Meals and special diets in hospital
• All medically necessary services
(Cont’d…)
Slide 18 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Part A, Non-Covered In-Hospital Expenses (…Cont’d)
• Personal convenience items
• Example: – Slippers, TV
– Non-medically necessary items
(Cont’d…)
Slide 19 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Part A, Other Covered Expenses
(…Cont’d)
• Rehabilitation
• Skilled-nursing
• Some personal convenience items for long-term illness or disabilities
• Home health visits
• Hospice care
• Not automatically covered – Must meet certain
criteria
Slide 20 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Part B, Supplemental
• Part B pays services and supplies not covered under Part A
• Not automatic
• Beneficiaries purchase – Pay monthly _________ premiums
(Cont’d…)
Slide 21 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Type of Items Covered by Part B
(…Cont’d)
• Physicians’ services
• Outpatient hospital services
• Home health care
• ________________ supplies and equipment Medically necessary
Slide 22 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Coding for Medicare Part B Services • Three coding systems used to
report Part B – CPT
– HCPCS
– ICD-10-CM/ICD-9-CM (Vol. 1 & 2)
Slide 23 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Health Insurance Portability and Accountability Act • Established 1996 • Administrative Simplification • Largest change • Includes:
– Electronic Transactions – Privacy – Security – National Identifier Requirements (NPI)
Slide 24 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Federal Register
• Government publishes changes in laws
• Coding supervisors keep current on changes
(Cont’d…)
Slide 25 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Issues of Importance in Federal Register (…Cont’d)
• _______ contains hospital facility changes
• ________ and _________ contain outpatient facility changes and physician fee schedule
October November December
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Federal Register
Figure: 1.3 From Federal Register, January 4, 2012, Vol. 77, No. 2, Rules and Regulations.
Slide 27 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Outpatient Resource–Based Relative Value Scale • RBRVS
• Physician payment reform implemented in 1992
• Paid physicians _____ of – 1. Physician’s charge for service
– 2. Physician’s _________ charge
– 3. ________ charge in locality
lowest
customary
Prevailing
Slide 28 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
National Fee Schedule
• Replaced RBRVS
• Termed Medicare Fee Schedule (MFS)
• Payment __% of MFS, after patient deductible
• Used for physicians and ________
80
suppliers
Slide 29 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Relative Value Unit
• Nationally, unit values assigned to each CPT code
• Local adjustments made: 1. Work and skill required
2. ________ costs
3. Malpractice costs
Overhead
(Cont’d…)
Slide 30 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Relative Value Unit (…Cont’d)
• Often referred to as ___ schedule
• ________, CMS updates RVU based on national and local factors
• Beneficiary Protection – Physician Payment Reform
– Omnibus Budget Reconciliation Act of 1989
– Maximum Actual Allowable Charge (MAAC) 1991
fee Annually
Slide 31 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Geographic Practice Cost Index (GPCI) and Conversion Factor (CF) • GPCI: Geographic Practice Cost Index
– Scale of cost variance of charge locations • Charge location may be entire state
• CF: Conversion Factor – National dollar amount – Paid on Medicare Fee Schedule basis – Converts RVUs to dollars – Updated yearly
Slide 32 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Medicare Fraud and Abuse
• Program established by Medicare – To decrease fraud and abuse
• Fraud – _________ deception to benefit
• Example: – Submitting for services not provided
Intentional
Slide 33 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Beneficiary Signatures
• Beneficiary signatures on file – Service, charges submitted without need for
patient signature
• Presents opportunity for _____ fraud
(Cont’d…)
Slide 34 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Fraud
(…Cont’d)
• Anyone who submits for Medicare services can be violator – Physicians
– Hospitals
– Laboratories
– Billing services
– ____ YOU
Slide 35 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Fraud Can Be
• Billing for services not provided
• Misrepresenting diagnosis
• Kickbacks
• _________ services
• Falsifying ______ necessity
• Routine _____ of copayment
Unbundling
medical
waiver
Slide 36 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Office of the Inspector General (OIG) • Each year develops Work Plan
• Outlines monitoring Medicare program
• _____ monitor those areas identified in plan MACs
Slide 37 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Complaints of Fraud
• Submitted orally or in writing to MACs or OIG
• Allegations made by anyone against anyone
• Allegations followed up by MACs and/or OIG
Slide 38 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Abuse
• Generally involves – Impropriety
– Lack of medical necessity for services reported
• Review takes place after claim submitted – May go back and do historic review
of claims
Slide 39 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Kickbacks
• Bribe or rebate for referring patient for any service covered by Medicare
• Any personal ____ = kickback
• A felony – Fine or
– Jail or
– Both
gain
Slide 40 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Protect Yourself
• Use your common sense
• Submit only truthful and accurate claims
• If you are unsure about charges – Check with _______ or supervisor physician
Slide 41 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Managed Health Care
• Network health care providers that offer health care services under one organization
• Group hospitals, physicians, or other providers
Slide 42 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Managed Care Organizations
• Responsible for health care services to an enrolled group or person
• Coordinates various health care services
• Negotiates with providers
Slide 43 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Preferred Provider Organization (PPO) • Providers form network to offer health care
services as group
• Enrollees who seek health care outside PPO ________
pay more
Slide 44 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Health Maintenance Organization (HMO) • Total package health care
• ___________ expenses minimal
• Assigned physician acts as _________ to refer patient outside organization
Out-of-pocket
gatekeeper
Slide 45 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
Drawbacks of Managed Care
• Organization has incentive to keep patient within organization – Services provided outside organization limited
– Patient must have approval to go outside organization if services to be covered