Chapter 001

Copyright Copyright ©© 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1

CHAPTER 1CHAPTER 1

REIMBURSEMENT, HIPAA, REIMBURSEMENT, HIPAA, AND COMPLIANCEAND COMPLIANCE


Third-Party Third-Party Reimbursement IssuesReimbursement Issues• Each coding system plays critical role Each coding system plays critical role

in reimbursementin reimbursement

• Your job is to Your job is to ______________ payment paymentoptimizeoptimize


Your ResponsibilityYour Responsibility

• Ensure accurate coding dataEnsure accurate coding data

• Obtain correct reimbursement for Obtain correct reimbursement for services renderedservices rendered

• ________________ (maximizing) is never (maximizing) is never appropriateappropriateUpcodingUpcoding


Population ChangingPopulation Changing

• Elderly fastest growing patient segmentElderly fastest growing patient segment

• By 2050, 20% of the population will be the By 2050, 20% of the population will be the elderlyelderly

• Medicare primarily for elderlyMedicare primarily for elderly


Medicare—Getting Bigger Medicare—Getting Bigger All the Time!All the Time!• By 2018, national health care spending By 2018, national health care spending

expected to reach $4.4expected to reach $4.4 trilliontrillion

• Health care will continue to expand to Health care will continue to expand to meet enormous future demandsmeet enormous future demands

– Job security for coders!Job security for coders!


Basic Structure MedicareBasic Structure Medicare

• Medicare program established in 1965 Medicare program established in 1965

– 2 parts: A and B2 parts: A and B

• Part Part __ : Hospital insurance: Hospital insurance

• Part Part __: Supplemental—nonhospital: Supplemental—nonhospital

– Example: PhysiciansExample: Physicians’’ services and medical equipment services and medical equipment

• PartPart __: Medicare Advantage, health care options : Medicare Advantage, health care options (Added later and formerly termed Medicare + (Added later and formerly termed Medicare + Choice)Choice)

• PartPart __: Prescription drugs: Prescription drugs

AA

BB

CC

DD


Those CoveredThose Covered

• Originally established for those 65 Originally established for those 65 and overand over

• Later disabled and permanent renal Later disabled and permanent renal disease (end-stage or transplant) addeddisease (end-stage or transplant) added

• Persons covered Persons covered ““______________________””beneficiariesbeneficiaries


Officiating OfficeOfficiating Office

• __________________________________________________________________________ (DHHS) (DHHS)

• Delegated to Centers for Medicare and Delegated to Centers for Medicare and Medicaid Services (CMS)Medicaid Services (CMS)

– CMS runs Medicare and MedicaidCMS runs Medicare and Medicaid

– CMS delegates daily operation to Medicare CMS delegates daily operation to Medicare Administrative Contractors (MAC)Administrative Contractors (MAC)

– MACs usually insurance companiesMACs usually insurance companies

Department of Health and HumanDepartment of Health and HumanServicesServices


Funding for MedicareFunding for Medicare

• Social security taxesSocial security taxes

– Equal match from governmentEqual match from government

• CMS sends money to MACsCMS sends money to MACs

• MACs handles paperwork and pays MACs handles paperwork and pays claimsclaims


Medicare Covers (Part B)Medicare Covers (Part B)

• Beneficiary pays Beneficiary pays

– ____% of cost of service % of cost of service

– + annual + annual __________________

• Medicare pays Medicare pays

– ____% covered services% covered services

2020

deductibledeductible

8080


Non-participating QIO Non-participating QIO ProvidersProviders• Payment sent to patientPayment sent to patient

• Non-QIOs receive 5% less than Non-QIOs receive 5% less than participating QIOsparticipating QIOs

• Slower claims processingSlower claims processing


Participating QIO ProvidersParticipating QIO Providers

• Signed agreement with MACsSigned agreement with MACs

• Agree to accept what MACs pay as Agree to accept what MACs pay as payment in fullpayment in full

– Accept AssignmentAccept Assignment

• Block Block ____ on CMS-1500 on CMS-15002727

(Cont(Cont’’d…)d…)


(…Cont(…Cont’’d)d)

• Block 27 on Block 27 on CMS-1500, CMS-1500, Accept Accept AssignmentAssignment

Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.


Why Be a Why Be a Participating Provider?Participating Provider?• MACs usually do not pay charges MACs usually do not pay charges

provider submitsprovider submits

– Significant decreaseSignificant decrease

• Participating providers receive Participating providers receive __% % more than non-participatingmore than non-participating

55



More Good Reasons More Good Reasons to Participate:to Participate:(…Cont(…Cont’’d)d)

• Check sent directly from MACs to Check sent directly from MACs to participating providerparticipating provider

• ____________ claims processing claims processing

• Provider names listed in a Provider names listed in a ________________

– Sent to all Sent to all __________________________

FasterFaster

directorydirectory

beneficiariesbeneficiaries


Part A, HospitalPart A, Hospital

• Hospitals submit charges on Hospitals submit charges on __________

• ICD-9-CM codes basis for paymentICD-9-CM codes basis for payment– MS-DRG (Medicare Severity Diagnosis Related MS-DRG (Medicare Severity Diagnosis Related

Groups) Groups)

• More on this topic in Chapter 26More on this topic in Chapter 26

UB04UB04



Part A, Covered Part A, Covered In-Hospital Expenses In-Hospital Expenses (…Cont(…Cont’’d)d)

• Semiprivate roomSemiprivate room

• Meals and special diets in hospitalMeals and special diets in hospital

• All medically necessary services All medically necessary services



Part A, Non-Covered Part A, Non-Covered In-Hospital Expenses In-Hospital Expenses (…Cont(…Cont’’d)d)

• Personal convenience items Personal convenience items

• Example:Example:

– Slippers, TVSlippers, TV

– Non-medically necessary itemsNon-medically necessary items



Part A, Other Covered Part A, Other Covered ExpensesExpenses(…Cont(…Cont’’d)d)

• RehabilitationRehabilitation

• Skilled-nursingSkilled-nursing

• Some personal Some personal convenience items convenience items for long-term illness for long-term illness or disabilitiesor disabilities

• Home health visitsHome health visits

• Hospice care Hospice care

• Not automatically Not automatically coveredcovered

– Must meet certain Must meet certain criteriacriteria


Part B, Supplemental Part B, Supplemental

• Part B pays services and supplies not Part B pays services and supplies not covered under Part Acovered under Part A

• Not automaticNot automatic

• Beneficiaries purchaseBeneficiaries purchase

– Pay monthly Pay monthly ____________________premiumspremiums



Type of Items Covered by Part BType of Items Covered by Part B


• PhysiciansPhysicians’’ services services

• Outpatient hospital servicesOutpatient hospital services

• Home health careHome health care

• __________________________________ supplies supplies and equipmentand equipmentMedically necessaryMedically necessary


Coding for Medicare Coding for Medicare Part B ServicesPart B Services• Three coding systems used to Three coding systems used to

report Part Breport Part B

– CPTCPT

– HCPCSHCPCS

– ICD-9-CM (Vol. 1 & 2)ICD-9-CM (Vol. 1 & 2)


Health Insurance Portability Health Insurance Portability and Accountability Actand Accountability Act

• Established 1996Established 1996

• Administrative SimplificationAdministrative Simplification

• Largest changeLargest change

• Includes:Includes:– Electronic TransactionsElectronic Transactions

– PrivacyPrivacy

– SecuritySecurity

– National Identifier Requirements (NPI)National Identifier Requirements (NPI)


Federal RegisterFederal Register

• Government publishes changes in laws Government publishes changes in laws

• Coding supervisors keep current on Coding supervisors keep current on changes changes



Issues of Importance in Issues of Importance in Federal RegisterFederal Register(…Cont(…Cont’’d)d)

• ______________ contains hospital facility contains hospital facility changeschanges

• __________________ and and __________________ contain contain outpatient facility changes and outpatient facility changes and physician fee schedulephysician fee schedule

OctoberOctober

NovemberNovember DecemberDecember


Federal Federal RegisterRegister

Figure: 1.3Figure: 1.3From From Federal Register,Federal Register, August 3, 2010, Vol. 148, August 3, 2010, Vol. 148, No. 8, Proposed Rules.No. 8, Proposed Rules.


Outpatient Resource–Based Outpatient Resource–Based Relative Value ScaleRelative Value Scale• RBRVSRBRVS

• Physician payment reform implemented Physician payment reform implemented in 1992in 1992

• Paid physicians Paid physicians ____________ of of

– 1. Physician1. Physician’’s charge for services charge for service

– 2. Physician2. Physician’’s s __________________ charge charge

– 3. 3. __________________ charge in locality charge in locality

lowestlowest

customarycustomary

PrevailingPrevailing


National Fee ScheduleNational Fee Schedule

• Replaced RBRVSReplaced RBRVS

• Termed Medicare Fee Schedule (MFS)Termed Medicare Fee Schedule (MFS)

• PaymentPayment ____% of MFS, after patient % of MFS, after patient deductibledeductible

• Used for physicians and Used for physicians and ________________

8080

supplierssuppliers


Relative Value UnitRelative Value Unit

• Nationally, unit values assigned Nationally, unit values assigned to each CPT codeto each CPT code

• Local adjustments made:Local adjustments made:

1.1. Work and skill required Work and skill required

2.2. ________________ costs costs

3.3. Malpractice costsMalpractice costs

OverheadOverhead



Relative Value UnitRelative Value Unit


• Often referred to as Often referred to as ______ schedule schedule

• ________________, CMS updates RVU based on , CMS updates RVU based on national and local factorsnational and local factors

• Beneficiary ProtectionBeneficiary Protection

– Physician Payment ReformPhysician Payment Reform

– Omnibus Budget Reconciliation Act of 1989Omnibus Budget Reconciliation Act of 1989

– Maximum Actual Allowable Charge (MAAC) 1991Maximum Actual Allowable Charge (MAAC) 1991

feefee

AnnuallyAnnually


Geographic Practice Cost Index Geographic Practice Cost Index (GPCI) and Conversion Factor (CF)(GPCI) and Conversion Factor (CF)

• GPCI: Geographic Practice Cost IndexGPCI: Geographic Practice Cost Index– Scale of cost variance of charge locationsScale of cost variance of charge locations

• Charge location may be entire stateCharge location may be entire state

• CF: Conversion FactorCF: Conversion Factor– National dollar amount National dollar amount

– Paid on Medicare Fee Schedule basisPaid on Medicare Fee Schedule basis

– Converts RVUs to dollarsConverts RVUs to dollars

– Updated yearlyUpdated yearly


Medicare Fraud and AbuseMedicare Fraud and Abuse

• Program established by Medicare Program established by Medicare

– To decrease fraud and abuseTo decrease fraud and abuse

• Fraud Fraud

– __________________ deception to benefit deception to benefit

• Example:Example:

– Submitting for services not providedSubmitting for services not provided

IntentionalIntentional


Beneficiary SignaturesBeneficiary Signatures

• Beneficiary signatures on fileBeneficiary signatures on file

– Service, charges submitted without need Service, charges submitted without need for patient signaturefor patient signature

• Presents opportunity for Presents opportunity for __________fraudfraud



FraudFraud


• Anyone who submits for Medicare Anyone who submits for Medicare services can be violatorservices can be violator

– PhysiciansPhysicians

– HospitalsHospitals

– LaboratoriesLaboratories

– Billing servicesBilling services

– ________YOUYOU


Fraud Can BeFraud Can Be

• Billing for services not providedBilling for services not provided

• Misrepresenting diagnosisMisrepresenting diagnosis

• KickbacksKickbacks

• ____________________ services services

• Falsifying Falsifying ______________ necessity necessity

• Routine Routine ____________ of copayment of copayment

UnbundlingUnbundling

medicalmedical

waiverwaiver


Office of the Inspector Office of the Inspector General (OIG)General (OIG)• Each year develops work planEach year develops work plan

• Outlines monitoring Medicare programOutlines monitoring Medicare program

• __________ monitor those areas identified monitor those areas identified in planin planMACsMACs


Complaints of Fraud or AbuseComplaints of Fraud or Abuse

• Submitted orally or in writing to MACs or OIGSubmitted orally or in writing to MACs or OIG

• Allegations made by anyone against anyoneAllegations made by anyone against anyone

• Allegations followed up by MACsAllegations followed up by MACs


AbuseAbuse

• Generally involvesGenerally involves

– Impropriety Impropriety

– Lack of medical necessity for services Lack of medical necessity for services reportedreported

• Review takes place after claim Review takes place after claim submitted submitted

– May go back and do historic review May go back and do historic review of claimsof claims


KickbacksKickbacks

• Bribe or rebate for referring patient for Bribe or rebate for referring patient for any service covered by Medicareany service covered by Medicare

• Any personal Any personal ________ = kickback = kickback

• A felonyA felony

– Fine or Fine or

– Jail or Jail or

– BothBoth

gaingain


Protect YourselfProtect Yourself

• Use your common senseUse your common sense

• Submit only truthful and accurate Submit only truthful and accurate claimsclaims

• If you are unsure about chargesIf you are unsure about charges

– Check with Check with __________________ or supervisoror supervisor physicianphysician


Managed Health CareManaged Health Care

• Network health care providers that offer Network health care providers that offer health care services under one health care services under one organization organization

• Group hospitals, physicians, or other Group hospitals, physicians, or other providersproviders



Managed Care Managed Care OrganizationsOrganizations(…Cont(…Cont’’d)d)

• Responsible for health care services Responsible for health care services to an enrolled group or personto an enrolled group or person

• Coordinates various health care Coordinates various health care servicesservices

• Negotiates with providersNegotiates with providers


Preferred Provider Preferred Provider Organization (PPO)Organization (PPO)• Providers form network to offer health Providers form network to offer health

care services as groupcare services as group

• Enrollees who seek health care outside Enrollees who seek health care outside PPO PPO ________________pay morepay more


Health Maintenance Health Maintenance Organization (HMO)Organization (HMO)• Total package health careTotal package health care

• ________________________ expenses minimalexpenses minimal

• Assigned physician acts as Assigned physician acts as ____________________ to refer patient outside organizationto refer patient outside organization

Out-of-pocketOut-of-pocket

gatekeepergatekeeper


Drawbacks of Managed CareDrawbacks of Managed Care

• Organization has incentive to keep Organization has incentive to keep patient within organizationpatient within organization

– Services provided outside organization Services provided outside organization limited limited

– Patient must have approval to go outside Patient must have approval to go outside organization if services to be coveredorganization if services to be covered


ConclusionConclusionCHAPTER 1CHAPTER 1

REIMBURSEMENT, HIPAA, REIMBURSEMENT, HIPAA, AND COMPLIANCEAND COMPLIANCE

Chapter 001

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Transcript of Chapter 001