CHAA Examination
Preparation
Pre-Encounter - Session IV
Pages 52-61
University of Mississippi Medical Center
What to Expect…
• This module covers various aspects of
Patient Access knowledge found in pages 5261 of the Pre-Encounter section of the 2010
CHAA Study Guide.
• A quiz at the end will measure your
understanding of the content covered.
Centers for Medicare and
Medicaid Services (CMS)
• CMS is a government agency created to
administer the largest FEDERAL health
programs. It also works with CHIP for
uninsured children.
• The overall goal of CMS is to assure health
security for its beneficiaries.
Centers for Medicare and
Medicaid Services (CMS)
• CMS looks out for their beneficiaries by
performing QUALITY ASSESSMENT and
PERFORMANCE IMPROVEMENT programs for
CMS accredited hospitals.
• They promote Health Standards and a high
quality of care by assigning PEER REVIEW
ORGANIZATIONS (PROs) to monitor and
improve healthcare in each state.
Peer Review Organizations
(PROs)
PROs have two main functions in serving CMS
beneficiaries:
1.) They conduct COOPERATIVE QUALITY
IMPROVEMENT PROJECTS to increase the quality
of care by examining and improving health-care
delivery processes.
2.) They provide BENEFICIARY PROTECTION AND
EDUCATION thorough mandatory case review of
beneficiary complaints and outreach activities.
Efficiency and Fiscal
Integrity
Efficiency:
• The Centers for Medicare Services (CMS) LEADS the
HEALTHCARE INDUSTRY in the use of ELECTRONIC
TECHNOLOGY for all phases of claims processing
which REDUCE ADMINISTRATIVE COSTS.
Fiscal Integrity:
• In 1992, CMS began paying physicians according to a
NATIONAL FEE SCHEDULE based on the work and
overhead costs associated with each medical
service.
DRG & APG(C)
In an effort to limit the increasing costs of
healthcare, CMS proposed a “Prospective Payment
System” which lists the amounts CMS will reimburse
for each procedure.
• DIAGNOSIS RELATED GROUP (DRG) – is the fee
schedule for all INPATIENT services.
• AMBULATORY PAYMENT GROUP (APG) – is the fee
schedule for OUTPATIENT services. It is also known
as the Ambulatory Payment Classification System
(APCs).
CMS Fraud and Abuse
• The Department of Justice (DOJ), Office of
Inspector General (OIG), and other federal
and state agencies work with CMS to prevent
fraud and abuse.
• Funding to combat fraud and abuse is
provided through HIPAA.
Medicare Rules
• Unintentional failure to follow CMS rules and
guidelines carries severe FINES and
PENALTIES.
• In cases of INTENTIONAL FRAUD, Medicare
will not only pursue the hospital, but the
INDIVIDUAL EMPLOYEE as well.
CMS Fiscal Intermediaries
• Fiscal Intermediary is a fancy word for a
“financial go-between.”
• These private agencies are contracted by
CMS to perform bill and claims processing
and pay benefits on behalf of Medicare.
• Basically, CMS outsources these services to
outside companies.
Fiscal Intermediary
Responsibilities
Fiscal Intermediaries are also responsible for:
• Determining whether services are MEDICALLY
NECESSARY and if they constitute an
APPROPRIATE LEVEL OF CARE.
• Deterring and detecting MEDICARE FRAUD.
• Auditing provider cost reports to ensure that
Medicare PAYS THE APPROPRIATE AMOUNT when
the BENEFICIARY HAS OTHER HEALTH
INSURANCE.
Medicare Eligibility
Requirements:
Medicare is a federal health insurance program
for:
• Patients age 65 and OLDER
• People of ANY AGE with END STAGE RENAL
DISEASE
• CERTAIN DISABLED people UNDER AGE 65
Medicare Card
A patient’s Medicare card will identify:
• If the patient has Part A and/or Part B
• When those benefits became effective
• The Medicare Claim number which is usually the
patient or spouse’s social security number with a
letter/number prefix.
Medicare Beneficiaries are automatically eligible and
must apply 3 months before their 65th birthday.
Medicare Part A
This is Hospital Insurance and helps pay for:
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INPATIENT HOSPITAL SERVICES
SKILLED NURSING FACILITY SERVICES (SNF)
HOME HEALTH SERVICES
HOSPICE CARE
Medicare Part B
This helps pay for:
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Doctor Services
Outpatient Hospital Services
Medical Equipment and Supplies
Emergency Room Visits
Ambulance Service
Medicare Part C
This is known also as the “Medicare Advantage
Plan.”
• In this plan, the beneficiary pays extra for a
PRIVATE INSURANCE COMPANY to manage
their Medicare coverage.
• It is usually in the form of an HMO or PPO.
• It usually results in more healthcare options.
Medicare Part D
This helps cover PRESCRIPTION DRUGS and MAY
lower prescription drug costs.
Medicare Miscellaneous Rules
• BENEFIT PERIOD – begins on the FIRST DAY of
services in an inpatient or SNF facility and ends 60
days after discharge IF that 60 days ISN’T
INTERRUPTED by SKILLED CARE in ANOTHER
FACILITY.
• Beneficiaries can have an UNLIMITED number of
benefit periods but must pay the inpatient
deductible for each period.
• 72 HOUR/3 DAY RULE – states that preadmission
testing or diagnostic services provided by the
admitting hospital within three days of admission BE
INCLUDED IN THE INPATIENT PAYMENT.
Medicare Miscellaneous Rules
• LIFETIME RESERVE DAYS – Medicare pays for 60 days
of hospitalization in instances where the patient is
an inpatient for MORE THAN 90 DAYS. They can be
used ONLY ONCE IN A LIFETIME.
• Except for certain limited cases in Canada and
Mexico, Medicare does not pay for treatment
outside the United States.
• Medicare (Part A) pays for skilled nursing home care
for REHABILITATION SERVICES ONLY. It doesn’t pay
for general custodial services.
“Important Message From
Medicare” Form
This form is given to ALL MEDICARE BENEFICIARIES in
INPATIENT HOSPITALS and it explains:
• Their rights to needed care and any follow-up care
after discharge.
• It provides a number to a Peer Review Organization
(PRO) to call if they feel they are being discharged
too early.
• Beneficiaries may remain in the hospital without
being charged while their case is being reviewed.
Hospice Care
• This assists with care for terminally ill
beneficiaries who select the hospice care
benefit.
• There are no deductibles but beneficiaries
pay limited costs for drugs and respite care.
Advanced Beneficiary
Notice (ABN)
The ABN should be given to the beneficiary to
sign if:
• Medicare MAY NOT consider the service to be
provided as MEDICALLY NECESSARY
- BECAUSE • If not, there is a good chance Medicare WILL
NOT PAY for the service and THE PATIENT
WILL BE BILLED FOR IT.
Advanced Beneficiary Notice
(ABN) Cont’d
• If the ABN has NOT BEEN SIGNED BEFORE SERVICE IS
provided and Medicare doesn’t pay for it, THE
PATIENT CANNOT BE HELD RESPONSIBLE for paying
the bill.
• If the ABN was signed before the service, the
patient may be billed.
• Many Fiscal Intermediaries are now using SOFTWARE
that compares the diagnosis to the service thereby
determining MEDICAL NECESSITY.
Medicare Secondary Payer
Questionnaire (MSPQ)
• The MSPQ is necessary because some
Medicare beneficiaries have other insurance
(not including Medigap) that must pay before
Medicare.
• The MSPQ should be completed on ALL
MEDICARE PATIENTS each time a service is
provided to assure that appropriate billing
guidelines are followed.
Medicare is Secondary
Payer if:
• Patient is 65 or older and covered by group health
insurance with an employer with 20 OR MORE
EMPLOYEES for whom they or their spouse is currently
working.
• Patient is under 65 and DISABLED, they or any
member of their family is currently working for an
employer with 100 OR MORE EMPLOYEES.
• Patient has Medicare because of permanent kidney
failure (ESRD).
• Patient has an illness or injury that is covered under
workers’ compensation, the federal black lung
program, no-fault insurance, or any liability
insurance.
Medicare Miscellaneous
Rules
• When a beneficiary cannot recall his/her retirement
date, but knows it occurred prior to their
entitlement date, you can use their Medicare
Entitlement Date as the retirement date.
• For recurring visits where patient has several
recurring visits for the same service(such as physical
therapy), all charges are entered into one account.
• For recurring visits, you are required to verify MSPQ
information every 90 days.
How Medicare Pays
• Medicare pays fixed amounts to hospitals
according to patient’s diagnosis based on the
DIAGNOSIS RELATED GROUPING (DRG –
INPATIENT) and AMBULATORY PAYMENT
CLASSIFICATION (APC – OUTPATIENT).
• Hospitals can receive a higher payment or
“add-on” for services if it serves a great
percentage of low-income patients or is an
approved teaching hospital.
Medicare Supplemental
Insurance
These are Private Insurance plans that pay
some or all of healthcare costs not covered
by Medicare:
- Employee Coverage - from a CURRENT employer
or union
- Retiree Coverage - from a FORMER employer or
union
- Medigap Coverage – from a private company or
group designed to help pay cost-sharing amounts
and uncovered services
Medicare Managed Care
• In most managed care plans, patients can only go
to certain doctors and hospitals that agree to
treat members of the plan.
• Doctors can join or leave the plan at any time.
• Patients need a referral to see a specialist.
• Some managed care plans offer a Point-of-Service
option which allows patients to go to other
doctors and hospitals who aren’t a part of the
plan.
• Managed Care Plans usually cost more, but often
provide more options for beneficiaries.
Private Fee-for-Service Process
• With this plan, the private company, rather
than Medicare, decides how much it and
patients pay for outlined services.
• Patients can go to any provider that accepts
the terms of the plan’s payment.
Medicaid
• Medicaid was established by federal
legislation in 1965 to provide health care
coverage for categories of low-income
people.
• States have the freedom to design their
program and decide:
– Eligibility standards
– What benefits and services to cover
– What payment rates to charge
Medicaid Qualifications
• Certain low income families with children
• Aged, blind, or disabled people on Supplemental
Security Income
• Certain low income pregnant women and children
• Certain people who would not otherwise be eligible
but qualify as the result of catastrophic medical
expenses