What is a summary report of patient receivables?
To monitor timely claims processing in a hospital, a summary report of "patient receivables" is generated frequently. Aged receivables can negatively affect a facility's cash flow; therefore, to maintain the facility's fiscal integrity, the HIM manager must routinely analyze this report.
What does S mean in APC?
Under APCs, payment status indicator "S" means. significant procedure, multiple procedure reduction does not apply. These are financial protections to ensure that certain types of facilities (e.g., children's hospitals) recoup all of their losses due to the differences in their APC payments and the pre-APC payments.
Is there a reimbursement concept for managed care?
In the managed care industry, there are specific reimbursement concepts, such as "capitation." All of the following statements are true in regard to the concept of "capitation," EXCEPT
Is Medicare Part B true?
Under Medicare Part B, all of the following statements are true and are applicable to nonparticipating physician providers, EXCEPT
What happened to a Medicare patient who fell in a neighbor's walkway?
A Medicare patient presents after slipping and falling in a neighbor's walkway. The cement had a large crack, which caused the pavement to raise and be unsteady. The neighbor has contacted his homeowner's insurance and they are accepting liability and have initiated a claim.
How long does Medicare have to be paid before it is paid?
d. Bill the Homeowner's first, then Medicare secondary if it is not paid within 120 days.
What is Medicare limiting charge?
The office, by state law, can charge the patient a limiting charge that is 10 percent above the Medicare fee schedule amount.
What does a patient need to see a specialist for?
A patient needs to see a specialist for a cardiac condition. She references her insurance handbook for a list of network providers that belong to that specialty. She may choose any physician she wishes and does not need a referral from her Internist to see the specialist. If she chooses an out-of-network physician, she will have to pay a higher co-insurance amount to see them. What type of insurance does this patient have?
What does CMS do?
a. CMS reviews all state plans to make sure they offer federal regulations.
What is a group contract?
A group contracts with a third party administrator to manage paperwork. This group pays for the operation of the insurance plan and the costs of administration. What type of plan does this represent?
Can a patient appeal a health plan decision?
c. Patients have the right to appeal a health plan's decision to deny payment for a claim or termination of health coverage.
What is Medicare Supplement?
Medicare supplement policies provide a significant amount of long-term care coverage. b. Medicaid provides long-term care coverage for individuals, regardless of income levels. c. Medicare and Medicaid are designed to cover a significant portion of the costs of long-term custodial or nursing home care.
How long does it take to enroll in Medicare Part B?
Open enrollment for Medigap policies spans a three-month period beginning on the first day of the month in which the individual is age 65 or above and enrolls in Medicare Part B. b. Open enrollment for Medigap policies spans a five-month period beginning on the first day of the month in which the individual is age 65 or above ...
Can Andrea get medicare?
d. Andrea can enroll in Medicare once her employer-sponsored coverage ends.
Can Genevieve be on Medicare?
a. Genevieve can enroll in Medicare once her employer-sponsored coverage ends.
Is Workers Compensation a secondary payor?
c. If Jane is injured at work, Workers Compensation is secondary payor
Does Mandy have health insurance?
Is only available to people age 65 and above. Mandy has a group health insurance plan through her employer. At the age of 70 she is still employed and covered by her employer group health plan, but also has Medicare coverage.
Is Medicare a secondary payer?
If individuals work beyond age 65 and remain under their employer's group health plan, Medicare may be a secondary payer. c. Medicare supplement insurance is most often purchased from private insurers. d. Medicare is a secondary payer to employer plans for individuals who have Medicare because of a covered disability.
What is Medicare Advantage?
Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies.
Can MSAs have a partial network?
I. MSAs may have either a partial network, full network, or no network of providers.
Is Daniel a Medicare beneficiary?
Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of SNP is likely to be most appropriate for him?
Can a woman enroll in Medicare Advantage?
She can enroll in any type of Medicare Advantage (MA) plan except an MA Medical Savings Account (MSA) plan.
Does Medicaid provide additional benefits?
Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers.
Do PFFS plans have Part D?
PFFS plans may choose to offer Part D benefits but are not required to do so.
How much less is Medicare reimbursement than a participating provider?
Regardless if a nonparticipating provider chooses to accept assignment on all claims or on a claim-by claim basis, their Medicare reimbursement is five percent less than a participating provider, as reflected in the annual Medicare Physician Fee Schedule.
What is a non-participating provider?
A nonparticipating provider is a provider involved in the Medicare program who has enrolled to be a Medicare provider but chooses to receive payment in a different method and amount than Medicare providers classified as participating. The nonparticipating provider may receive reimbursement for rendered services directly from their Medicare patients.
What is the CMS requirement for Medicare?
The CMS requires all Medicare carriers to monitor nonparticipating physicians for compliance with Medicare limiting charges. This review is conducted to establish compliance with Title XVIII of the Social Security Act, Sections 1842 (B) and 1842 (J) that limit the amount a non-participating physician can charge for services to Medicare beneficiaries. Every two weeks, a report is produced that identifies claims submitted by non-participating physicians.
What happens when a physician bills a primary insurer but receives no payment?
When a physician bills a primary insurer above his limiting charge, but receives no payment because the insurer applies the amount to the patient's deductible, the physician must adjust his bill to the limiting charge or lower and may then bill Medicare.
When did Medicare stop limiting charge exceptions?
Effective October 1, 1998, the Limiting Charge Exception Reports (LCERs) were no longer mailed to nonparticipating providers, practitioners or suppliers. The limiting charges submitted by nonparticipating providers are still monitored by Medicare staff. In the absence of the limiting charge exception reports, providers, other practitioners and suppliers can use their remittance notices to calculate the limiting charge amounts.
When does limiting charge apply to Medicare?
The limiting charge applies when Medicare is the secondary payer, unless the claim to the primary payer is assigned, or the primary payer requires the physician to accept its payment as payment in full.
What is a special note for elective surgery?
Special Note on Elective Surgery - If non-emergency surgery, which is expected to cost $500.00 or more is to be performed , and the physician is not planning to accept assignment, the non-participating physician must give the patient a written notice prior to performing the surgery. The notice must include information such as the charge for the surgery, what Medicare is likely to allow and pay and the amount the patient can expect to be their out-of-pocket expense.