Monday, May 18, 2015

How do you determine whether prescription drug coverage is creditable coverage? and about Home Health Providers

How do you determine whether prescription drug coverage is creditable coverage?

Prescription drug coverage is creditable if the actuarial value of the prescription drug coverage offered by the entity equals or exceeds the actuarial value of the standard prescription drug coverage under Medicare (Part D coverage). Entities must determine creditable coverage status for each benefit option offered. In general, the actuarial value test measures whether the expected amount of paid claims, on average, for all Medicare eligible individuals covered under the entity’s prescription drug coverage is expected to pay at least as much as the expected amount of paid claims under the standard prescription drug benefit under Medicare Part D. Entities should calculate the value of the standard Medicare prescription drug benefit for a given plan year based on the initial coverage limit, cost-sharing and out-of-pocket threshold for the standard prescription drug coverage under Part D in effect at the start of the entity’s plan year.

If an entity is not an employer or union that is applying for the Retiree Drug Subsidy, it can use the simplified determination of creditable coverage status annually to determine whether its prescription drug plan’s coverage is creditable or not.

Home Health Providers

This page provides basic information about being certified as a Medicare and/or Medicaid home health provider and includes links to applicable laws, regulations, and compliance information.

A Home Health Agency (HHA) is an agency or organization which:
•    Is primarily engaged in providing skilled nursing services and other therapeutic services;Has policies established by a group of professionals (associated with the agency or organization), including one or more physicians and one or more registered professional nurses, to govern the services which it provides;
•    Provides for supervision of above-mentioned services by a physician or registered professional nurse;
•    Maintains clinical records on all patients;
•    Is licensed pursuant to State or local law, or has approval as meeting the standards established for licensing by the State or locality;
•    Has in effect an overall plan and budget for institutional planning;
•    Meets the federal requirements in the interest of the health and safety of individuals who are furnished services by the HHA; and
•    Meets additional requirements as the Secretary finds necessary for the effective and efficient operation of the program.
For purposes of Part A home health services under Title XVIII of the Social Security Act, the term “home health agency” does not include any agency or organization which is primarily for the care and treatment of mental diseases.

A Home Health Agency may be a public, nonprofit or proprietary agency or a subdivision of such an agency or organization.

1.    Public agency is an agency operated by a State or local government.  Examples include State-operated HHAs and county hospitals.  For regulatory purposes, “public” means “governmental.”
2.    Nonprofit agency is a private (i.e., nongovernmental) agency exempt from Federal income taxation under §501 of the Internal Revenue Code of 1954.  These HHAs are often supported, in part, by private contributions or other philanthropic sources, such as foundations.  Examples include the nonprofit visiting nurse associations and Easter seal societies, as well as nonprofit hospitals.
3.    Proprietary agency is a private, profit-making agency or profit-making hospital.

Wednesday, May 6, 2015

"Incident to" and the Initial Visit - Evaluation & Management (E/M) Service Guidelines

Novitas Solutions Medical Review (MR) Department has observed a continued trend of the utilization of non-physician practitioners to perform initial office visits as "incident to" services. Documentation reviewed by the MR Department indicates that a non-physician practitioner performs the initial visit and the supervising physician documents a note in the medical record similar to the following:

"I have reviewed the Physician Assistant's note, examined the patient and agree with..."
“Nurse practitioner performed the history and physical and I was present for the entire encounter and my treatment plan is as follows……”

This is incorrect use of the non-physician practitioner and incorrect billing under the "incident to" guidelines. This article explains the Medicare definition of "incident to" services and the criteria that must be met to properly bill "incident to" services.

An initial history and physical performed by a non-physician practitioner, although the physician is documented as being present or in the office suite and immediately available, is not covered under the "incident to" guidelines. As outlined below, the physician MUST perform the initial service. This includes the history and physical, examination portion of the service, and the treatment plan. It is expected that the physician will perform the initial visit on each new patient to establish the physician-patient relationship.

Novitas Solutions MR will deny or down code claims for initial office visits billed as "incident to" when a non-physician practitioner performs the initial history and physical .
CMS defines "incident to" services as “services or supplies furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”

In order to be covered as "incident to" the physician’s service, the following criteria must be met:
services must be an integral, although incidental, part of the physician’s professional service,
commonly rendered without charge or included in the physician’s bill,
of a type that are commonly furnished in physician’s offices or clinics, and
furnished by the physician or by auxiliary personnel under the physician’s direct supervision

"Incident to" services must be performed under the direct supervision of the physician. CMS directs that “Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”

CMS further indicates, under direct supervision, “This does not mean, however, that to be considered "incident to", each occasion of service by auxiliary personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a personal professional service by the physician. Such a service or supply could be considered to be "incident to" when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of the course of treatment.” Hospital and skilled nursing facility services cannot be billed as "incident to" at any time.

Wednesday, April 29, 2015

The Differences Between Crossover and Medigap


Crossover is an automatic claim filing service used by Railroad Medicare and Medicare Part B contractors to send claim information to your supplemental insurance after Palmetto GBA has processed a Medicare claim for you. This saves you the time of filing a claim with your supplemental insurer.

In order for you to be in the crossover program, you must enroll with your supplemental insurer. Once you have enrolled, Railroad Medicare will receive, on a regular basis from the supplemental insurer, a list of patients in the crossover program. Once the lists are received from the crossover companies, claim information is electronically compared with the list to determine if there is a match.

If there is a match, the information is transferred to the requesting crossover company. The information forwarded to the requesting company is similar to the information provided on a Medicare Summary Notice (MSN). If your name and Health Insurance Claim (HIC) number appear on the list, your claims processed during that month will be forwarded to your supplemental insurer. You may be enrolled in the crossover program with more than one supplemental insurer. You can only enroll in the crossover program through your supplemental insurer, not through Railroad Medicare. Likewise, if you want to stop the crossover program, you must do this through your supplemental insurer.

The first claim submitted to Railroad Medicare will not cross over. This is because your eligibility information must be added to Railroad Medicare's system. As long as your name and HIC number appear on a company's monthly crossover listing, Railroad Medicare will continue to forward claims information to the supplemental insurer.

Some supplemental insurers do not offer crossover. You should contact your insurance company to see if your policy is eligible for the crossover program.

Medicaid offers a crossover program with Medicare. The crossover list consists of eligible Medicaid recipients. However, if you are on crossover with a supplemental insurer, we will only forward information to the supplemental insurer, not to Medicaid. In order for you to be on crossover with Medicaid, you cannot be on crossover with any supplemental insurer. If you have both Medicare and Medicaid, your health care providers must accept assignment on all Medicare claims.

Medigap is a health insurance policy or other health benefit plan offered by a private entity to people entitled to Medicare benefits. It is specifically designed to supplement Medicare benefits by filling in some of the 'gaps' that Medicare does not cover, such as deductibles, coinsurance amounts or other limitations. It does not include limited benefit coverage available to Medicare beneficiaries such as 'specified disease' or 'hospital indemnity' coverage. It explicitly excludes a policy or plan offered by an employer to employees or former employees as well as that offered by a labor organization to members or former members.

Medigap eliminates the need for you or your participating health care providers to file separate claims to Medigap insurers. Railroad Medicare will automatically send claim information to Medigap insurers, if you have elected to assign your Medigap benefits to a participating provider.

The Medigap plan differs slightly from the crossover process. In order for information to be forwarded to a Medigap insurer, the following criteria must be met:
1. Physicians must be participating (PAR)
2. The supplemental policy must meet the definition of a Medigap policy
3. Physicians must include the following Medigap policy information on the CMS-1500 claim form or electronic claim:
o Name of Medigap insurer (Item 9)
o Enter the other insured's policy or group number preceded by MEDIGAP, MG OR MGAP (Item 9a)
o Leave blank (reserved for NUCC use) (Item 9b)
o Leave blank (reserved for NUCC use) (Item 9c)
o Enter the Coordination of Benefits Agreement (COBA) Medigap-based Identifier (ID) (Item 9d)

Monday, April 20, 2015

Railroad Medicare Coverage of Supplies if You Have Diabetes

Railroad Medicare covers certain supplies if you have Medicare Part B and have diabetes. These supplies include:
Blood glucose self-testing equipment and supplies
Therapeutic shoes and inserts
Insulin pumps and the insulin used in the pumps

Blood Glucose Self-testing Equipment and Supplies 
Blood glucose self-testing equipment and supplies are covered for all people with Medicare Part B who have diabetes. This includes those who use insulin and those who do not use insulin. These supplies include:
Blood glucose monitors
Blood glucose test strips
Lancet devices and lancets
Glucose control solutions for checking the accuracy of testing equipment and test strips
Railroad Medicare covers the same type of blood glucose testing supplies for people with diabetes whether or not they use insulin. However, the amount of supplies that are covered varies.
If you:
1. Use insulin, you may be able to get up to 100 test strips and lancets every month, and 1 lancet device every 6 months
2. Do not use insulin, you may be able to get 100 test strips and lancets every 3 months, and 1 lancet device every 6 months
If your doctor documents why it is medically necessary, Railroad Medicare will cover additional test strips and lancets for you.
Medicare and Railroad Medicare will only cover blood glucose self-testing equipment and supplies if you get a prescription from your doctor which includes:
That you have diabetes
What kind of blood glucose monitor you need and why
Whether or not you use insulin
How often you need to test your blood glucose
Medicare will not pay for any supplies not asked for, or for any supplies that were sent to a beneficiary automatically from suppliers. This includes blood glucose monitors, test strips, and lancets. Also, if a beneficiary goes to a pharmacy or supplier that is not enrolled in Medicare, Medicare will not pay. The beneficiary will have to pay the entire bill for any supplies from non-enrolled pharmacies or non-enrolled suppliers.
All Medicare-enrolled pharmacies and suppliers must submit claims for blood glucose monitor test strips. You cannot submit a claim for blood glucose monitor test strips yourself. You should make sure that the pharmacy or supplier accepts assignment for Medicare-covered supplies. If the pharmacy or supplier accepts assignment, Medicare will pay the pharmacy or supplier directly. You should only pay your coinsurance amount when you get your supply from your pharmacy or supplier for assigned claims. If your pharmacy or supplier does not accept assignment, charges may be higher, and you may pay more. You may also have to pay the entire charge at the time of service and wait for Medicare to send you its share of the cost.
Before you get a supply, be sure to ask the supplier or pharmacy the following questions:
Are you enrolled in Medicare?
Do you accept assignment?
If the answer to either of these two questions is 'no,' you may wish to consider calling another supplier or pharmacy in your area that answers 'yes' to be sure your purchase is covered by Medicare.

Therapeutic Shoes and Inserts 
If you have Medicare Part B, have diabetes, and meet certain conditions (see below), Railroad Medicare will cover therapeutic shoes if you need them. The types of shoes that are covered each year include one of the following:
One pair of depth-inlay shoes and three pairs of inserts or
One pair of custom-molded shoes (including inserts) if you cannot wear depth-inlay shoes because of a foot deformity and two additional pairs of inserts
Note: In certain cases, Medicare may also cover shoe modifications instead of inserts.
In order for Medicare to pay for your therapeutic shoes, the doctor treating your diabetes must certify that you meet all of the following three conditions:
You have diabetes
You have at least 1 of the following conditions in one or both feet
o Partial or complete foot amputation
o Past foot ulcers
o Calluses that could lead to foot ulcers
o Nerve damage because of diabetes with signs of problems with calluses
o Poor circulation, or
o Deformed foot
You are being treated under a comprehensive diabetes care plan and need therapeutic shoes and/or inserts because of diabetes
Medicare also requires the following:
A podiatrist or other qualified doctor must prescribe the shoes, and
A doctor or other qualified individual like a pedorthist, orthotist, or prosthetist must fit and provide the shoes to you
Medicare helps pay for one pair of therapeutic shoes and inserts per calendar year, and the fitting of the shoes or inserts is covered in the Medicare payment for the shoes.

Insulin Pumps and the Insulin Used in the Pumps 
Insulin pumps worn outside the body (external), including the insulin used with the pump, may be covered for some people with Railroad Medicare coverage who have diabetes and who meet certain conditions. If you need to use an insulin pump, your doctor will need to prescribe it.

Railroad Medicare covers the cost of insulin pumps and the insulin used in the pumps. However, if you inject your insulin with a needle (syringe), Medicare Part B does not cover the cost of the insulin, but your Medicare prescription drug benefit (Part D) covers the insulin and the supplies necessary to inject it. This includes syringes, needles, alcohol swabs and gauze. Your Medicare Part D plan will cover the insulin and any other medications to treat diabetes at home as long as you are on the Medicare Part D plan’s formulary.

Coverage for diabetes-related durable medical equipment (DME) is provided as a Medicare Part B benefit. The Medicare Part B deductible and coinsurance or copayment applies after the yearly Medicare part B deductible has been met.

Sunday, April 5, 2015

The Annual Wellness Visit (AWV) Exam: Understanding Your Coverage

The Affordable Care Act of 2010 brought new covered services, as well as changes to existing services regarding copayments and deductibles. The addition of the Annual Wellness Visit (AWV) exam is meant to help you maintain good health through a yearly visit with your primary care doctor.

Before the AWV exam, the ‘Welcome To Medicare’ exam (also called your Initial Preventive Physical Exam, or IPPE) benefit was available to you during the first twelve months of your Railroad Medicare eligibility. This initial exam established your health baseline from which the doctor could measure changes.

The new Annual Wellness Visit is the next step towards using all the information gathered in your 'Welcome to Medicare' exam. In addition, there is no co-pay, and it is not charged toward your Railroad Medicare deductible.

Your Annual Wellness Visit will:

Update medical and family history
Update measurement of height, weight, body-mass index and blood pressure
Document changes you made in using other health care professionals
Document changes other health care professionals may have made, like medications
Look for any cognitive changes or impairments
Update your screening schedule
Update the list of risk factors
Provide health advice based off this AWV information and make referrals if needed

Though it may sound like a routine physical exam, the Annual Wellness Visit isn’t - the AWV is a preventive service. Medicare does not consider a routine physical exam a preventive service.

When you schedule your AWV with your doctor’s office, make sure they document it so Railroad Medicare can pay for this annual benefit.

Monday, March 30, 2015

Observation Care: Are You ‘Inpatient’ or ‘Outpatient’? It Makes a Difference

If you are in the hospital, occupying a bed, are you an inpatient of the hospital, or not? You probably think you are, but that may not necessarily be true. Here’s why:

Being ‘inpatient’ means you have been formally admitted to the hospital with a doctor’s order. Being ‘outpatient’ means that you are getting emergency department services, observation services, or having outpatient surgery, tests, etc., at the hospital, but a doctor has not written an order to admit you into the hospital. The amount of time you spend in the hospital, even if it is overnight, does not determine your hospital status. You are not an inpatient until you are admitted to the hospital formally on a doctor’s order.

Outpatient observation services are performed in a hospital on the hospital’s premises, including use of a bed and at least occasional monitoring by a hospital’s nursing or other staff, to help your doctor determine if it’s necessary to admit you formally to the hospital as an inpatient, or if you can be discharged. Generally, patients are not kept in outpatient observation status for more than 48 hours.

Why does your hospital status matter? Your status, inpatient or outpatient, has an effect on how Medicare pays the hospital, and how much you may have to pay for the hospital services. You can pay more for services received when you are in outpatient hospital observation status because instead of being responsible for one Part A deductible for all of your hospital services, you are instead responsible for a separate copayment for each outpatient hospital service. The total of your copayments for outpatient services, including tests, procedures and observation, can be more than your Part A deductible would be as an inpatient. Also, Medicare Part B does not cover self-administered drugs, including your prescription drugs and over-the-counter drugs that you may receive as an outpatient.

What determines whether you are admitted as an inpatient? Generally, you will not be admitted as an inpatient if you are not expected to need medically necessary hospital care for two of more midnights.

Here are some examples of how Medicare pays for observation services:

I am admitted to the hospital from the emergency room, based on a doctor’s order. Part A will pay for the hospital stay, and Part B (Railroad Medicare) will pay for the doctor’s services.
In another scenario, I visit the emergency room, I am sent to the intensive care unit or any other room so that my condition can be monitored. My condition gets better and the doctor lets me go home. Part A pays nothing, and Part B (Railroad Medicare) pays for the doctor’s services.
In cases where Part A does not pay, the outpatient services (such as the doctor’s services, lab services, radiology/x-rays, etc.) are paid for by Part B. I pay my deductibles and co-pays out of pocket. Each of these services is billed separately.
I visit the emergency room and the hospital staff keeps me for two nights. If one of those nights a doctor writes an order for me to be admitted to the hospital, Part A will pay for my hospital stay, and Part B pays the rest, minus my deductibles and co-pays.

There are many other cases and scenarios and situations in which Part A may or not pay. The most critical situation is for patients going to a skilled nursing facility (SNF) after a hospital stay. If the beneficiary has not been a hospital inpatient for three consecutive days, Medicare will not cover the SNF stay or services – regardless if the patient was physically at the hospital for three days or more.

Tuesday, March 17, 2015

General Home Health Care Information

Palmetto GBA Railroad Medicare (original Medicare) covers Part B services, such as doctors’ visits, surgeries, preventive services, lab tests and some ambulance transports or services furnished by other non-practitioners or suppliers.

Home health is a covered service under the Part A Medicare benefit. It consists of part-time, medically necessary skilled care (nursing, physical therapy, occupational therapy, and speech-language therapy) that is ordered by a physician.

In order to be eligible for Home Health Care, you must be 'homebound' and a doctor certifies that you are homebound.  Being homebound means that:

Leaving your home isn’t recommended due to your condition (you are confined to your home)
You are unable to leave home without help (such as by using a wheelchair or walker, needing special transportation, or getting help from another person)
Leaving home takes a considerable and difficult effort
Other requirements for Home Health Care:
You are under the care of a physician
You receive services under a plan of care that was created and is reviewed on a periodic basis by a physician
You are in need of skilled nursing care on an intermittent basis, or you need physical therapy or speech-language pathology services; or you have a continuing need for occupational therapy after your need for skilled nursing, physical therapy or speech-language pathology has ended
If your only need is for skilled oversight of unskilled services (a long way of saying the management and evaluation of the care plan established for you), then your doctor must include a statement that explains how Home Health Care is clinically and medically necessary for you

The doctor that creates the plan of care and certifies that you need Home Health Care must be enrolled with Medicare. They must also be a doctor of medicine, osteopathy or podiatric medicine. They have to certify that you are receiving Home Health Care under their care.
Your doctor must certify that you need Home Health Care when the plan of care is created, or very soon after that. The certification has to be signed and dated by the physician that created your plan of care, and this must be completed before a home health agency bills Medicare.
Home health services include skilled nursing care (on a part-time or intermittent basis). They must be medically necessary and ordered by your doctor and provided by a registered nurse (RN) or a licensed practical nurse (LPN).

Skilled nursing care can include giving IV drugs or shots, changing wound dressings, tube feedings, etc.  Services that can be safely given by you yourself or by a non-medical person without nurse supervision are not considered skilled nursing care.
Other covered home health services include physical therapy, occupational therapy, and speech-language pathology services when deemed medically necessary as long as one of the following applies:

Your doctor expects your condition will improve in a reasonable and fairly predictable period of time
You need a skilled therapist to safely and effectively create a maintenance program or to perform maintenance therapy

As with all covered Medicare services, the number, frequency and duration of these services must be medically necessary and reasonable.

Home Health Care can also help pay for medical social services when they are ordered by your doctor to help you with social or emotional difficulties related to your illness. It also can assist with paying for medical supplies, such as wound dressings, when they are ordered as part of your care.
Home Health Care doesn’t cover everything.  Some things which are excluded from this program include 24-hour day care at your home, meals delivered to your home, shopping/cleaning/laundry assistance and other non-skilled custodial care when these services are not related to your plan of care.

Sunday, March 8, 2015

what is bone density or Bone Mass measurment

Bone Density: Time to Get It Tested

Bone Mass Measurement (BMM), or bone density screening is a test that identifies bone mass, detects bone loss, and may determine bone quality. BMM can be performed with a bone 'densitometer' or an approved bone 'sonometer system.' Bone densitometry uses an X-ray or some other form of radiation, and the test will determine your bone density according to the rate at which this radiation is absorbed by your bones. There are usually three methods of testing: a stationary machine kept in one location, such as your doctor’s office or a hospital; a mobile unit, such as you see with mammography units, or with a portable machine. Bone sonometers are ultrasound machines and do not use radiation. You often see these machines in doctors’ offices. This is the same ultrasound technique used for gallbladders, bladders, etc.

Medicare may cover BMM screening once every two years (at least 23 months have passed since the month the last covered BMM was performed) or more often when medically necessary for persons who are at risk for osteoporosis and meet other conditions. This test is free (deductible and coinsurance/copayment are waived) if your doctor or health care provider accepts assignment. To 'accept assignment' means your doctor or health care provider or suppler has a signed agreement to be paid directly by Medicare and to accept the Medicare approved amount. They cannot bill you for any more than the Medicare deductible and coinsurance.

Medicare covers bone mass measurement when:

It is ordered by a physician or qualified health care practitioner who is treating you, following an evaluation of the need for the BMM
The patient meets one of the following conditions:
o Is a woman whose physician/qualified non-physician practitioner treating her finds the patient to be estrogen-deficient and at clinical risk for osteoporosis based on medical history and other findings
o Is an individual with vertebral abnormalities shown by an X-ray that indicate osteoporosis, osteopenia (when bones have decreased calcification, decreased density or reduced mass) or vertebral fracture
o Is receiving (or expected to receive) glucocorticoid (steroid) therapy at certain dosages for more than three months
o Has primary hyperparathyroidism
o Is being monitored to assess the response to or effectiveness of an FDA-approved osteoporosis drug therapy

As our bodies age, our bones can become increasingly porous, brittle, and can fracture. Decrease in bone density can be reduced with diet and exercise and fall prevention. Some medications may also be used to treat decreased bone mass. Talk to your doctor to see if you need a BMM.

Wednesday, February 25, 2015

Physical Therapy Plan of Care Requirements

The Centers for Medicare & Medicaid Services (CMS), is continuing to focus on lowering the Comprehensive Error Rate Testing (CERT) claims paid error rate. Currently, one area of concern identified in the CERT data is denial of outpatient rehabilitation therapy services due to missing physician/non-physician practitioner signature and dates on the certification of the plan of care. This has led to Novitas Solutions, Inc recouping overpayments totaling over $164.70. More importantly, when CMS and CERT extrapolate these errors to the universe they will account for approximately $19.3 million in claims payment errors for the November 2011 report.

Medicare defines rehabilitative services as those services that lead to "recovery or improvement in function and, when possible, restoration to a previous level of health and well-being."
Outpatient rehabilitation therapy services must relate directly to a written treatment plan (also known as the plan of care or plan of treatment).  Medicare states "The plan of care shall contain, at minimum, the following information: diagnoses, long term treatment goals, and type, amount, duration, and frequency of therapy services."

The plan of care is established by a physician, non-physician practitioner, physical therapist, an occupational therapist, or a speech-language pathologist  The signature and professional identity of the person who established the plan of care and the date it was established must be documented within the plan of care.  The plan of care must be established before the therapy treatment can begin.

Establishing the plan of care is different than certifying the plan of care.  Medicare states that certification of the plan of care requires a dated signature on the plan of care, or some other document, by the physician or non-physician practitioner who is the primary care provider for the patient.  In the absence of a formal certification document, a physician progress note indicating the physician's agreement with the plan of care is acceptable. The certification of the plan of care should occur as soon as possible after it is established or within 30 calendar days of the initial therapy treatment.  Payment may be denied if the physician does not certify the plan of care; therefore, the therapist should forward the plan to the physician as soon as it is established. Recertification of the plan of care, which also requires a physician or non-physician signature and date, should occur whenever there is a significant change in the plan or every 90 days from the initial plan of care certification.  A therapy provider, per Medicare, may obtain a verbal order for certification or recertification of the plan of care; however, the verbal order must be signed and dated by the physician/non-physician practitioner within 14 calendar days.

In order to avoid an error and the denial of services, when submitting documentation for review, be sure to:
Have established a complete initial plan of care, making certain to include your signature, your professional identification (i.e. PT, OT, etc.), and have the date the plan was established.

Ensure that the plan of care is certified (recertified when appropriate) with a physician/non-physician practitioner signature and date.

Clearly document when the plan of care has been modified, including how it was modified and why the previous goals could not be met.

Wednesday, February 18, 2015

Advance Beneficiary Notice of Non-coverage: When Should You Sign an ABN?

Medicare has broad coverage, but there are some services that are not covered because they are considered reasonable, medically necessary, and appropriate. The purpose of the ABN is to give you the necessary information to make informed decisions about whether or not to get the services your provider is suggesting.

The following are some examples of when an ABN can be used for non-covered services:
Services where there is no legal obligation to pay (e.g., for the purchase of some vaccines). In those cases, your doctor can charge Medicare for administering the vaccine, but they cannot charge Medicare for the vaccine.
Services paid for by a government entity other than Medicare
Personal comfort items
Routine eye care
Dental care
Routine foot care

ABNs cannot be issued for services that the provider knows is medically necessary and is covered by Medicare. In addition, an ABN cannot be issued for emergency ambulance transportation because the patient is presumed to be under ‘great duress’. An ABN cannot be issued to a patient if they are under great duress.

An ABN must be given to you (or your representative) prior to receiving the item or service in question. The Centers for Medicare & Medicaid (CMS) mandates your provider give you the ABN far enough in advance for you to have time to consider your options and make an informed choice.

CMS has created a standardized ABN form to use; however, it does allow your health care provider to use their own form, as long as it contains the same information.

If your provider asks you to sign an ABN, the document must:

Give the name or description of the service they are providing
Provide a statement that explains why they believe the services may not be covered by Railroad Medicare. Some common statements are: 'Medicare does not pay for this test for your condition,' 'Medicare does not pay for this test as often as this (denied as too frequent)', or 'Medicare does not pay for experimental or research tests.'
Give you the estimated cost of the service or procedure
Provide you with three options, worded in the following ways:

o Option 1. 'I want the (service or procedure) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.'

o Option 2. 'I want the (service or procedure) listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.'
o Option 3. 'I don’t want the (service or procedure) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.'

The ABN will also have a place for additional information, such as a dated witness signature.
There must be a place on the ABN for you to sign and date, which indicates you have reviewed the document and understand the information in it. You cannot sign the ABN in advance of the rest of the notice.

Some points to remember:
Just because you sign an ABN does not mean Railroad Medicare will not pay for the service. Federal law still requires the claim be submitted for proper review.

Even if you sign the ABN and Railroad Medicare denies payment, you are still entitled to appeal the decision. You can pay the provider and later have your money returned to you from the provider if your appeal is successful.

If you have a secondary insurance, have the provider submit the claim to Railroad Medicare for denial. Some secondary insurances may cover services that Railroad Medicare does not.

Medical Billing

What is the overall Billing process?

The physician doesn’t get paid for his services immediately after they are rendered. Majority of the patients have insurance coverage and details of such coverage are provided to the physician before treatment. It is the responsibility of the physician to submit claims to the insurance company and get paid for his services. Submitting Claims and getting paid is a lengthy process and involves a lot of rules and regulatory systems and is very complicated. The physician needs to adhere to all these rules before submitting claims. This is the concept of Medical Billing. Sometimes the physician cannot provide his entire attention to this activity. He entrusts this activity to Billing Companies. This is a process of the physician providing rights to Billing Companies to bill Medical Insurance claims in order to save his time energy, and money.

After the provider renders services to the patient, the billing company will submit bills to the insurance company/ payer, using the insurance information that was last provided, as well as information about the reason for the examination, and the exact type of procedure performed.

Medical coding is the process of converting Medical terms to numeric code and it required Medical knowledge skills.

Medical billing is the process of submitting the claims and get paid behalf of provider.

I have listed the important process in Medical Billing. Each process is very important.

1. Insurance verification.

2. Demo and Charge entry process.

3. Claim submission.

4. Payment posting.

5. Action on denials or Denial management or Account receivables.

Insurance verification

Process started from here and usually front desk people are doing this process. Its a process of verifying the patients insurance details by calling insurance or through online verification. If this department works well, we could resolve more problem. We have to do this even before patient appointment.

Demo and Charge entry process

Demographic entry is nothing but capturing all the information of patients. It should be error free.

Charge-entry is one of the key departments in Medical Billing. Key department?? Yes, that's true. It is the keying-in department in Medical Billing. After receiving the super bills from the Doctor's office, it gets passed through the coding department, and then comes to the charge-entry department.

A Charge-entry person also has one other vital role to perform. That is, to look-up the codes entered in the claim, and to assign the relevant charges for those codes.

Claim submission Process

The next step after demographics and charge entry is claim generation. Claims may be paper claims or electronic claims. There are various types of forms for paper claims. The most widely used form is Health Care Finance Admin-1500 designed by the Health Care Financing Administration.

Electronic transmission of claims is the modern way of sending claims with less paper work. The most common means of transmission are through internet . The claim information is directly loaded into the insurance company's computer system or to the clearing house.

Payment Posting Process

Once the claims reach the carriers and they complete processing, they issue a check and prepare an Explanation of Benefits . The checks and the Explanation of Benefits would be sent to the pay-to address with the carrier or in the Health Care Finance Administrators.

In this processing we have accounted the money into the account as per the Explanation of Benefits. Now a days we are using Electronic payment posting also.

Action on denials or Denial management or Account Receivables

This is a most important function in the process flow of data. Unless this is taken care of, insurance balance will only be on an upward trend.

Problem in Medical Billing

•Inaccurate or lack of coding

• Incomplete claims

• Lack of supporting documentation

• Poor communication with the payer

• Not billing for services rendered

* Not being follow up AR balance claims

The person who is doing this process will be called Medical billing specialist.

Who is Medical Billing Specialist.

Medical billing Specialist is the one who is handling the below process and having well knowledge in each and every process.

* Insurance verification process

* Patient demographic and charge entry process.

* Submitting the claims by electronic as well as paper method. Tracking various claim submission report.

* Payments posting process for insurance as well as patient.

* Denial management.

* Insurance followup management.

* Insurance appeal process.

* Handling patient billing inquiries.

* Patient statement process.

* Preparing monthly reports such as revenue report and account receivable report and as per the provider requirement.

Medical Billing Specialists are in charge of reviewing patient charts and documents. They prepare and review all medical insurance claims based on the rules and regulations of insurance companies. Medical Billing Specialists also review insurance communications, payment and rejection notices to properly track all claims and payments.

Medical Billing specialist Professional

If a person is computer literate he is a fit enough candidate to take up the profession of medical billing and medical coding. However he will need to be trained and be aware of a lot of new information before he can start working effectively. He has to learn about the medical billing software and must be familiar with and master the various commands used while working with it.

Who are medical coders and how is it related to medical billing? Medical billing is a sub specialty of medical coding. Medical coding is the first step in the billing process. All patient records are maintained using the ICD-9 index system so that it is compliant with the federal rules.

A medical Biller’s most important skill includes filling up of the various medical forms correctly without any mistakes what so ever. All information required should be complete without any mistake at all. And the work will be include the following

Patient demographic entry

Insurance enrollment

Charge entry

Insurance verification

Billing and reconciling of accounts

Payment posting

Insurance authorization

Medical coding

Scheduling and rescheduling

Account receivable follow-ups and collections

Is it worth taking a medical billing program?

Usually don't spend too much cost on Medical billing program because the program will not do anything with real experience. What you learn from these kind of program will not be going to match with when you are working in the real environment. Hence just use as the start kind of program and get the real time experience even in small salary and later you can come up with more demanding one.

Problem of In House Processing of Medical Claims

Medical claims are generally very complex and have long extended details. While processing medical claims, one has to be highly critical and do efficient follow-up in order to get results. The process requires a lot of time and effort. And even after all this, there can be cases where files get lost or a small error can ruin the entire lot and everything has to be re-submitted again. Usually practice staff can be held up with lot of current work rather than submitting the claim and resubmitting the corrected claim hence it will lead to time delay on payment flow and it will affect all the relationship with in the practice. Even cost wise is also not effective when compare to outsourcing.

Advantage of Medical Billing Outsource

Medical Billing Company helps you in managing all your billing requirements proficiently. By choosing right medical billing company, you can get benefit such as improved financial strength.

Medical Billing task is very tedious and time consuming. However, billing must require more accuracy and special attention to strengthen the financial condition of clinical or hospital. You can do this task at own or assign to clinical staff but you have to be pleased with low patients satisfaction. Medical billing company can help you in supportive task. By efficient medical service, you will get highly satisfied patients.

A Medical Billing service can improve the efficiency of your billing system, reduce denials, cut down operating costs, boost reimbursements and save valuable time that can be devoted to patient care. These services are better equipped to adapt to continuously changing billing codes and industry requirements.

* Prince is low compare to doing it in house

* Dedicated Highly Skilled Professionals

* No need to maintain the hardware . Ability to perform Medical Billing remotely, using the software of your choice

* Usually Maximum reimbursements and fewer denials

* Accuracy is high when compare

* Faster transaction

Question need to ask when Medical Billing Outsourcing

1. Check with their referral and how long they are doing this business.

2. Are they HIPAA compliance

3. Where they are doing their work. If possible just visit there.

4. Data security.

5. Compare the price with others.

6. what are the reports they will provide

7. Your specialty wise question

8. Their software skills.

Services and process involved in Medical Billing

* Coding ( CPT, ICD-9, and HCPCS)

* Patient Demographics Entry

* Charge Entry – All specialties

* Payment Posting (Manual and Electronic)

* Payment Reconciliation

* Denials/rejections analysis, re-billing

* Accounts Receivable Follow-up

* Systemic A/R projects, re-billing

* Collection Agency Reporting

* Refunds

Medical Billing Salary Range

Depending on the education qualification, the hourly rate varies from $12-$15. Another most important factor that affects billing pay is how long someone has worked in the field. Medical specialist with experience of 1 year earns around $12 per hour. Those who have more experience in billing earn up to $16 per hour. However, the geographic location also plays a role in pay scale. For instance, areas where cost of living is high, the pay will be more. Billers who work in New York City, Houston, Chicago and California are able to pull a good amount of salary. Work locations such as hospital, billing company or private practice will also affect the salary. Since there are lots of factors which affect the salary of billing, it is really not easy to predict the pay scale. Studies have shown that 50% of people earned around $35,000-$45,000 annually.

Most of the medical Billers are paid hourly, rather than annually. While Biller who is experienced can earn around $40,000 a year as an independent contractor working from home, a billing and coding specialist who runs his own firm can earn $100,000 a year. However, people who are searching for home based job should be very careful. There is lots of fraud going on in this field. These spammers charge hundred to thousand dollars and in exchange they claim they will help to get a placement in billing. They also promise that medical billing job can earn a substantial amount of money and no experience required. But in reality, those who paid to get a job end up with no job, no money. Billing is a very competitive field, so without experience or training in medical billing field, it is almost impossible to get a job.

Selecting Medical Billing Software - 10 things to consider

1. The first step is to evaluate your needs. And when evaluating different systems look for a package that goes one step ahead of billing. Choose a medical practice management system MPP. This will handle considerably more that just medical billing.

2. Determine whether the system handles electronic transmission of claims, direct billing for patients, co-pays, co-insurance, and expenses not covered by insurance.

3. Weigh the pros and cons of different medical billing systems and ask to see a system in operations. Always check out the references yourself.

4. Look for a medical billing management system that is user friendly. When a vendor demonstrates get your office staff to be present. This way you will be able to check how the software functions. Any software must be easy to use to be productive. The system should be fool proof.

5. Ask whether the medical billing software is a traditional system, one that will work on your office computers or an application service provider system (ASP), one that will process data at the software company’s data center.

6. Always get quotes from at least three medical billing software providers.

7. Ask whether they are offering an evaluation period or trial. This will enable you to know in actuality whether the system works or not.

8. Find out about training your office people, up-gradation of system, and whether the software is compatible with your office computer systems

.9. Find out whether the system will handle appointment scheduling, maintenance of records and so on apart from electronic medical records, SOAP notes, and billing. Choose a system that is comprehensive.

10. An ideal Medical Billing software system must include aspects like payment posting, reconciliation; follow up, secondary submission, and patient billing.Choose a transparent billing system that enhances your office efficiency. Install a system that you can use not one that will lead to frustration and problems.Medical billing systems must free your time and that of your office staff not make you run in circles. Choose a system with care.


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