True/False
Non-participating physicians have an option regarding accepting assignment on Medicare patient.
TRUE
A nonpar may choose to accept or not accept assignment on a case to case basis. If they do not accept, they may charge the limiting charge (up to 115%). If they do accept, they must accept Medicare's allowed amount as payment in full.
Custodial needs.
NONCOVERED
Custodial services are those that assist the patient with personal needs. (dressing, bathing, eating, etc.). They are not considered medically necessary. * This does not include home health care which is covered by Medicare Part A.
The document which explains to the provider decisions made on a claim and the services for which they paid.
remittance advice (RA)
A RA is a notice of payment and explains any adjustments made to payment during the Medicare adjudication process.
Medigap is offered to beneficiaries by _________.
Private insurance carriers.
A monthly premium is paid by the beneficiaries and the Medigap plan typically pays deductibles, copays and coinsurance. In some cases, Medigap may pay for services that are not covered by Medicare.
Which president signed Medicare into legislation in 1965.
Lyndon B. Johnson
The number of Medicare benefit periods a patient can have for hospital care is limited.
FALSE
Benefit periods are unlimited and are not based on the calendar year.
Screening colonoscopy.
COVERED
Once every 120 months (10 years) or every 24 months for high-risk patients.
The ACA set a time limit policy for Medicare claims submission of _________ of date of service.
Within 12 months
Medicare will deny claims if they arrive after the deadline date and they are not subject to appeal.(*Except in limited circumstances)
How many types of Medigap plan options are currently available to beneficiaries (2019-2020)?
10
Plan options are: A, B, C, D, F, G, K, L, M, and N.
What does DHHS stand for?
Department of Health and Human Services
The DHHS works with state and local governments throughout the country to do research and provide public health services, food and drug safety programs .
All person's age 65 who meet eligibility requirements for Medicare receive Medicare Part B (outpatient coverage).
FALSE
Many individuals delay applying for Part B benefits because they are still covered by their own or their spouse's EGHP.
Drugs for weight loss or weight gain.
NONCOVERED
These drugs are excluded from coverage under Medicare.
Medicare does not allow for the standardized waiving of copayments. Medicare regulations require that a patient be billed at least ___ times before the balance is adjusted off as uncollectable.
3
You must ask for copayments. It is okay if they refuse to pay, but you have to ask.
Individuals with a Medicare Part C (Medicare Advantage) plan are eligible to apply for Medigap insurance. True or False?
FALSE
Medigap coverage is not available to all individuals who have Medicare coverage.
What does HACRP stand for?
Hospital-Acquired Condition Reduction Act
A program established to provide an incentive for hospitals to reduce hospital-acquired conditions. The worst-performing hospitals are subject to a payment reduction.
Medicare provides insurance for disabled workers of any age.
TRUE
Cosmetic surgery.
NONCOVERED
Cosmetic surgery is never covered under Medicare.
What do the acronyms CARC and RARC on a Medicare remittance advice represent?
Claim Adjustment Reason Codes (explain why the MAC pays a particular service line differently than was on the original claim) Ex: procedure code is inconsistent with patient's age.
Remittance Advise Remark Codes (give further information about an adjustment that cannot be explained with a CARC) Ex: incorrect dates, etc.
Medigap plans can be changed ______. Not just during open enrollment.
Any time of the year.
However, there’s generally no reason to change unless you’ve had a rate increase and are shopping for a lower rate.
This is a comprehensive listing of accepted charges or established allowances for specific medical procedures identified by procedural codes. CMS develops these for physicians, ambulance services, clinical laboratory services, and DME.
Medicare Fee Schedule (MFS)
MSP (Medicare Secondary Payer) rules state that Medicare is the secondary payer when an aged worker has benefits under a GHP (group health plan) with more than 10 covered employees.
FALSE
More than 20 employees.
Dentures.
NONCOVERED
Dentures are never covered under Medicare.
If the MAC makes an overpayment (up to $25) on a claim, once it is identified the health care organization has ___ days to report and return it.
60
If it is more than $25, the MAC will initiate the overpayment recovery process by sending an initial demand letter requesting repayment. If overpayment is not repaid to the MAC in full within 30 days, interest will be charged.
A slightly different variation of a Medigap policy is ____________. This policy has the same coverage as a regular Medigap policy, but there is a restriction on where beneficiaries can obtain medical care.
Medicare Select
Beneficiaries must obtain medical care from a list of specified network doctors and providers.
How many blocks are on the paper CMS-1500 form?
33