Certified Access Associate Exam

Certified Access Associate Exam

Study Guide

2016

Medicare

Medicare Part A - Inpatient hospital care

How often is it covered?

Medicare Part A (Hospital Insurance)covers hospital services, including semi-private rooms, meals, general nursing, drugs as part of your inpatient treatment, and other hospital services and supplies. This includes the care you get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long-term care hospitals, inpatient care as part of a qualifying clinical research study, and mental health care.

What's not covered

·  Private-duty nursing

·  Private room (unlessmedically necessary)

·  Television and phone in your room (if there's a separate charge for these items)

·  Personal care items, like razors or slipper socks

Who's eligible?

All people with Part A are covered when all of these are true:

·  A doctor makes an official order which says you need 2 or more midnights of medically necessary inpatient hospital careto treat your illness or injury and the hospital formally admits you.

·  You need the kind of care that can be given only in a hospital.

·  The hospital accepts Medicare.

·  The Utilization Review Committee of the hospital approves your stay while you're in a hospital.

Your costs in Original Medicare

·  $1,288deductiblefor eachbenefit period.

·  Days 1–60: $0coinsurancefor each benefit period.

·  Days 61–90: $322 coinsurance per day of each benefit period.

·  Days 91 and beyond: $644 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime).

·  Beyondlifetime reserve days: all costs.

Medicare Part B – Outpatient Medical Care

Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considerednecessary to treat a disease or condition.

If you're in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

Part B covers 2 types of services

·  Medically necessary services:Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.

·  Preventive services:Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

You pay nothing for most preventive services if you get the services from a health care provider who acceptsassignment.

Part B covers things like:

·  Clinical research

·  Ambulance services

·  Durable medical equipment (DME)

·  Mental health

o  Inpatient

o  Outpatient

o  Partial hospitalization

·  Getting a second opinion before surgery

·  Limited outpatient prescription drugs

2 ways to find out if Medicare covers what you need

1.  Talk to your doctor or other health care provider about why you need certain services or supplies, and ask if Medicare will cover them. If you need something that's usually covered and your provider thinks that Medicare won't cover it in your situation, you'll have toread and sign a noticesaying that you may have to pay for the item, service, or supply.

2.  Find out if Medicare covers your item, service, or supply.

Medicare coverage is based on 3 main factors

1.  Federal and state laws.

2.  National coverage decisions made by Medicare about whether something is covered.

3.  Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

What's not covered by Part A & Part B?

Medicare doesn't cover everything. If you need certain services that Medicare doesn't cover, you'll have to pay for them yourself unless you have other insurance or you're in aMedicare health planthat covers these services.

Even if Medicare covers a service or item, you generally have to pay yourdeductible,coinsurance, and copayments.

Some of the items and services that Medicare doesn't cover include:

·  Long-term care(also calledcustodial care)

·  Most dental care

·  Eye examinations related to prescribing glasses

·  Dentures

·  Cosmetic surgery

·  Acupuncture

·  Hearing aids and exams for fitting them

·  Routine foot care

An Important Letter from Medicare - IMM

Hospital Discharge Appeal Notices

Hospitals are required to deliver the Important Message from Medicare (IM), CMS-R-193 to all Medicare beneficiaries and Medicare Advantage plan enrollees who are hospital inpatients. The information on the IM informs hospitalized inpatient beneficiaries of their hospital discharge appeal rights. Beneficiaries who choose to appeal a discharge decision must receive the Detailed Notice of Discharge (DND) from the hospital or their Medicare Advantage plan, if applicable. These requirements were published in a final rule, CMS-4105-F: Notification of Hospital Discharge Appeal Rights, which became effective on July 2, 2007.

Advanced Beneficiary Notice – ABN

The ABN is a written notice you must issue to a Fee-For-Service beneficiary before furnishing items or services that are usually covered by Medicare but are not expected to be paid in a specific instance for certain reasons, such as lack of medical necessity. The following CMS notices are approved for this purpose: ™

·  Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131; ™

·  Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNFABN), Form CMS-10055;

·  Hospital-Issued Notice of Noncoverage (HINN).

The ABN allows the beneficiary to make an informed decision about whether to get the item or service that may not be covered and accept financial responsibility if Medicare does not pay. If the beneficiary does not get written notice when it is required, he or she may not be held financially liable if Medicare denies payment, and you may be financially liable if Medicare does not pay. The ABN is used for Medicare Part B (outpatient) and Part A (limited to hospice, Home Health Agencies, and Religious Nonmedical Health Care Institutions only) items and services. You must issue the ABN when: ™ You believe Medicare may not pay for an item or service; ™ Medicare usually covers the item or service; and

Medicare is expected to deny payment for the item or service because it is not medically reasonable and necessary for this beneficiary in this case or for one of the reasons listed in the “When You Must Issue an ABN” section below. Services must meet specific medical necessity requirements contained in the statute, regulations, and manuals and specific medical necessity criteria defined by National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) (if any exist for the service being reported). For every service billed, you must indicate the specific sign, symptom, or patient complaint that makes the service reasonable and necessary.

Common reasons for Medicare to deny an item or service as not medically reasonable and necessary include care that is: ™

·  Experimental and investigational or considered “research only”; ™

·  Not indicated for diagnosis and/or treatment in this case; ™

·  Not considered safe and effective; or ™

·  More than the number of services Medicare allows in a specific period for the corresponding diagnosis.

When You Must Issue an ABN

You must issue an ABN when you expect Medicare may deny payment for an item or service because: ™

·  It is not considered reasonable and necessary under Medicare Program standards; ™

·  The care is considered custodial; ™

·  Outpatient therapy services are in excess of therapy cap amounts and do not qualify for a therapy cap exception; ™

·  A beneficiary is not terminally ill (for hospice providers only);

·  A beneficiary is not homebound or there is no need for intermittent skilled nursing care (for home health services only).

When should you NOT issue an ABN

You may not issue an ABN on a routine basis or when there is no reasonable basis to expect that Medicare may not cover the item or service. You must ensure a reasonable basis exists for noncoverage associated with the issuance of each ABN. Some exceptions to the routine notice prohibition include: ™

·  Experimental items and services; ™

·  Items and services with frequency limitations for coverage; ™

·  Medical equipment and supplies denied because the supplier had no supplier number or the supplier made an unsolicited telephone contact;

·  Services that are always denied for medical necessity.

Other Prohibitions You cannot issue an ABN to: ™

·  To shift liability and bill the beneficiary for the services denied due to a Medically Unlikely Edit (MUE);

·  A beneficiary in a medical emergency or under great duress (compelling or coercive circumstances).

o  ABN use in the emergency room or during ambulance transports may be appropriate in some cases for a medically stable beneficiary who is not under duress;

·  Charge a beneficiary for a component of a service when Medicare makes full payment through a bundled payment; ™

·  Transfer liability to the beneficiary when Medicare would otherwise pay for items and services.

MSP – Medicare Secondary Payer

The MSP provisions protect the Medicare Trust Fund by ensuring Medicare does not pay for items and services when other health insurance coverage is primarily responsible for paying. The MSP provisions apply to situations where Medicare is not the primary or first payer of claims.

Are There Any Exceptions to the MSP Provisions?

There are no exceptions to the MSP provisions. Federal law takes precedence over State laws and private contracts. Even if an entity believes it is the secondary payer to Medicare due to State law or the contents of its insurance policy, the MSP provisions apply when billing for services.

What Happens if the Primary Payer Denies a Claim?

n the following situations, Medicare may make payment, assuming the service is a Medicare-covered and payable service and the provider files a proper claim: •

·  A no-fault or liability insurer does not pay during the “paid promptly” period or denies the medical bill;

·  A WC program denies payment (for example, where WC excludes a particular medical condition);

·  The beneficiary has exhausted a WC Medicare Set-Aside Arrangement (WCMSA);

·  A GHP denies payment for services because:

o  The beneficiary has exhausted plan benefit services;

o  The beneficiary has no coverage under the GHP;

o  The beneficiary needs services not covered by the GHP.

When submitting a claim to Medicare in these situations, you should include information showing why the other payer denied the claim, made an exhausted benefits determination, or both.

When May Medicare Make a Conditional Payment?

Frequently, there is a long delay between an injury and the decision by the primary payer in a contested compensation case. Medicare may make conditional payments to avoid imposing a financial hardship on you and the beneficiary awaiting a decision in a contested case.

A conditional payment occurs where Medicare is not the primary payer, and yet, it makes a reimbursable payment on behalf of its beneficiaries for Medicare-covered services until the compensation case is resolved. Medicare may make conditional payments for covered services in liability (including self-insurance), no-fault, and WC situations under the following circumstance:

·  Liability (including self-insurance), no-fault, or WC insurer is responsible for payment;

·  The claim is not expected to be paid promptly.

INSURANCE TERMINOLOGY

HSA

Health Savings Accounts (HSAs) were created in 2003 so that individuals covered by high-deductible health plans could receive tax-preferred treatment of money saved for medical expenses.

EOB

Explanation of Benefits (EOB). An EOB does look like a bill. It contains the date of service, the code used to bill a particular service to an insurance company, the fee charged by the healthcare provider, the allowed amount under the third-party payers’s contractual fee schedule, the patient’s responsibility under the terms of their coverage, the payment made by the payer, and the contractual write-off. The final entry of each line item is usually the titled something along the lines of, “what you owe,” or, “your responsibility.” This is why some patients confuse an EOB with a medical bill. Like most medical billing transactions, EOBs consist of medical code, not only the Healthcare Common Procedure Coding System (HCPCS Level I and Level II) codes, but also explanation codes that have been established by the Healthcare Portability and Accountability Act of 1996 (HIPAA). These explanation codes are easily understood by professional medical billers who are schooled in the language of healthcare reimbursement, but they are a mystery to laypeople who only encounter them in EOBs. While each EOB normally includes a definition of the adjustment and adjudication codes, they are often in fine print and their definitions are not always apparent to a person unfamiliar with reading them.

Coordination of Benefits

Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with more than one insurance to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan).

Primary Insurance

Primary insurance coverage protects against medical expenses up to the policy's limit, regardless of whatever other insurance you hold. The primary insurance coverage always kicks in first before any secondary insurance coverage begins. Such secondary policies come into play only once the primary insurance coverage has been completely exhausted.

Secondary Insurance

Supplemental or secondary health insurance is merely another policy that serves to “wrap around” your primary healthcare policy. When you’re sick, your primary insurer picks up the brunt of your medical expenses and is usually billed by your care provider. Your doctor then bills you for any additional charges, such as copays or coverage limits, your primary insurer won’t spring for. If you have secondary insurance, you may then submit these charges to that insurer for reimbursement. While your secondary insurance may not cover all of your out-of-pocket costs, it can help defray large expenses in many cases.

Tertiary Insurance

The word "tertiary" literally means "third," so a tertiary insurance policy provides coverage beyond an insured party's primary and secondary policies. The tertiary insurance company works with the other two insurers on "coordination of benefits," an agreement on which company will pay which part of a claim. A tertiary insurance policy kicks in only when the primary and secondary policies are inadequate.