Healthcare Chapter 9

Questions and Answers

The timely filing period for claims for Part B providers under the Affordable Care Act is _____.

Within one calendar year after the date of service

As a result of Medicare issuing about _____ in payments per year with significant amounts of improper payments, the Medicare Integrity Program was enacted.

$5 billion

$3 trillion

$100 million

$500 billion (correct)

Lab work may be performed at which of the following locations?

Ambulatory surgery centers

Physician's offices (correct)

Urgent care facilities

Off-site labs (correct)

What should a provider do if a claim has not been paid after thirty days?

Contact the payer using the telephone or electronic claim status inquiry. Signup and view all the answers

Services of allied health professionals provided under the physician's direct supervision that may be billed under Medicare are called _____.

Incident-to services Signup and view all the answers

What should practices do if covered and noncovered services are performed for a patient on the same date?

Split the bill Signup and view all the answers

Which of the following statements are true about roster billing?

The claims do not have to be sent electronically. Signup and view all the answers

All lab work for Medicare patients is regulated by _____ rules.

Clinical Laboratory Improvement Amendments Signup and view all the answers

What does the Medicare assignment code C indicate?

Not assigned Signup and view all the answers

When is an insurance type code required?

When a claim is sent to Medicare when Medicare is not the primary payer Signup and view all the answers

Which of the following medical staff members perform incident-to services?

Physician assistants Signup and view all the answers

If a patient is covered by Medicare and a Medigap plan, Medicare will ________ send a claim to Medigap for secondary payment.

automatically Signup and view all the answers

What is the name of a simplified billing process for vaccines?

Roster billing Signup and view all the answers

The Medicare assignment code _____ indicates the provider accepts Medicare assignment.

A Signup and view all the answers

Which insurance type code is used to identify an auto insurance policy as the primary payer?

AP Signup and view all the answers

If a patient is covered by Medicare and a Medigap plan, how many claims are sent to Medicare?

One Signup and view all the answers

The Medicare program is managed by ______________.

Centers for Medicare and Medicaid Services (CMS) Signup and view all the answers

Which of the following individuals would be eligible to receive Medicare benefits?

A person who is sixty-five and has paid FICA taxes for at least forty calendar quarters Signup and view all the answers

Medicare Part A is also called _____.

Hospital Insurance Signup and view all the answers

If enrollment in Part B takes place more than twelve months after a person's initial enrollment period, there is a _____ percent increase in the premium for each year the beneficiary failed to enroll.

10 Signup and view all the answers

In which of the following areas were changes made to Medicare as a result of the Medicare Modernization Act?

Better benefits and lower costs for Part C enrollees Signup and view all the answers

What is the federal medical insurance program established in 1965 under Title XVIII of the Social Security Act?

Medicare Signup and view all the answers

What benefits are offered under the Medicare Advantage Plus Prescription Drug plan?

It combines a prescription drug plan with a Medicare Advantage plan. Signup and view all the answers

A retired federal employee who is over the age of sixty-five and enrolled in Civil Service Retirement System (CSRS) is eligible for _____.

Medicare Signup and view all the answers

What is the Medicare number most often called?

Medicare beneficiary identifier Signup and view all the answers

Most people eligible for Medicare Part A do not pay a premium for coverage if they or their spouse has _____ quarters of Medicare-covered employment.

Forty Signup and view all the answers

What is the role of Medicare administrative contractors?

They handle claims and related functions for both Parts A and B. Signup and view all the answers

Which of the following services are covered under Medicare Part B?

Medical equipment Signup and view all the answers

When was the Medicare Modernization Act enacted?

2003 Signup and view all the answers

How much is the coinsurance for physicians' services covered under Medicare Part B?

20 percent Signup and view all the answers

What benefits are provided to eligible members under Medicare Part D?

Prescription drug plans Signup and view all the answers

What determines the services that are covered under Medicare?

Federal legislation Signup and view all the answers

Which of the following elements are found on a Medicare card?

Effective dates for Part A and B Signup and view all the answers

Upon enrollment in the Medicare program, providers are issued a(n) _____.

Provider transaction access number Signup and view all the answers

The Medicare Modernization Act required Medicare to replace the Part A fiscal intermediaries and Part B contractors with _____.

MACs Signup and view all the answers

Providers located in HPSAs are eligible for _____ percent bonus payments from Medicare.

10 Signup and view all the answers

Which of the following services are a covered benefit under Medicare Part B?

Emergency care Signup and view all the answers

MPFS was developed from the _____ system.

RBRVS Signup and view all the answers

Which of the following services are excluded under Medicare?

Eye refraction Signup and view all the answers

Participating providers may bill patients for services that are excluded from the Medicare program with a written notification called a(n) _____.

Voluntary ABN Signup and view all the answers

What is the purpose of the PTAN?

It is used for authentication purposes. Signup and view all the answers

On the ABN form, blanks A-C comprise the _____.

Header Signup and view all the answers

What is an HPSA?

A geographic area in which physicians who participate in Medicare receive bonuses. Signup and view all the answers

Which of the following types of descriptors may be used in Blank D on the ABN form?

Item Signup and view all the answers

Which of the following are true under Medicare Part B?

It covers inpatient hospital care. Signup and view all the answers

How many choices are listed in Blank G?

Three Signup and view all the answers

What are payment arrangements for Medicare PAR providers?

PAR providers must accept the charge amounts listed in the MPFS as the total payment amounts. Signup and view all the answers

The provider may use Blank _____ to provide additional clarification that the provider believes will be of use to the patient.

H Signup and view all the answers

Which form did the voluntary ABN replace?

NEMB Signup and view all the answers

What do ABN modifiers indicate?

Whether services are considered medically necessary Signup and view all the answers

Who completes the Header section of the ABN?

Provider Signup and view all the answers

How much are providers paid by Medicare who elect not to participate in the Medicare program but who accept assignment on a claim?

5 percent less than PAR providers Signup and view all the answers

Blanks D-F on the ABN form are part of the _____ section.

Body Signup and view all the answers

Under the Medicare limiting charges clause, non-PAR providers may not charge a Medicare patient more than _____ percent of the fee listed in the non-PAR MFS.

115 Signup and view all the answers

The Options Box section on the ABN form must be filled in by the _____.

Patient Signup and view all the answers

What is an MSN?

A remittance advice from Medicare sent to beneficiaries Signup and view all the answers

How many blanks are part of the Additional Information section of the ABN?

One Signup and view all the answers

What percentage of all Medicare beneficiaries are enrolled in group managed care plans called Medicare Advantage and Medicare Part C?

70 Signup and view all the answers

What should be appended to CPT/HCPCS codes on Medicare claims when an ABN has been signed?

Modifiers Signup and view all the answers

What are the most restrictive plans of the Medicare CCP plans?

HMOs Signup and view all the answers

Non-PAR providers decide whether to accept assignment on a ________ basis.

Claim-by-claim Signup and view all the answers

Under a Medicare private fee-for-service plan, patients receive services from _____.

Medicare-approved providers Signup and view all the answers

What are non-PAR physicians subjected to under the Medicare payment guidelines?

Limiting charges Signup and view all the answers

What does the Medical Savings Account pay for under the Medicare Advantage plan?

Expenses for covered services Signup and view all the answers

Which former form does the MSN replace?

EOMB Signup and view all the answers

_____ are private insurance plans that beneficiaries may purchase to cover the unpaid amounts in Medicare coverage.

Medigap plans Signup and view all the answers

A(n) _____ is responsible for providing all Medicare-covered services except hospice care in return for predetermined capitated payment.

MAO Signup and view all the answers

A(n) _____ plan is a plan an individual may receive when retiring from a company.

Supplemental insurance Signup and view all the answers

Which of the following are Medicare coordinated care plans?

PPOs Signup and view all the answers

Medicare requires the use of the _____ for coding services.

HCPCS Signup and view all the answers

Who operates the Medicare private fee-for-service plan?

Private contracted insurance companies Signup and view all the answers

Which modifier does the principal physician of record use with the E/M code when billed?

AI Signup and view all the answers

_____ created a new plan for Medicare called a Medical Savings Account.

MMA Signup and view all the answers

Which federal legislation changed the timely filing period for Medicare Part B claims?

Affordable Care Act Signup and view all the answers

Which of the following are gaps paid by Medigap plans?

Coinsurances Signup and view all the answers

What is the purpose of the Medicare Integrity Program?

To identify and address fraud, waste, and abuse Signup and view all the answers

What type of benefits do supplemental insurance plans provide?

Benefits similar to those offered in the employer's standard group health plan Signup and view all the answers

When are CCI updates issued?

Quarterly Signup and view all the answers

Medicare defines _____ as those sent to one or more Medicare contractors from the same provider for the same beneficiary, the same service, and the same date of service.

Duplicate claims Signup and view all the answers

In 2010, Medicare stopped paying for all consultation CPT codes from the _____ section except for G-codes.

E/M Signup and view all the answers

Under what conditions should practices split the bill when preparing claims?

When covered and noncovered services are both performed for a patient on the same day Signup and view all the answers

What is the timely filing period for claims for Part B providers under the Affordable Care Act?

1 year Signup and view all the answers

Study Notes

Medicare Administration and Eligibility

Managed by the Centers for Medicare and Medicaid Services (CMS).
Eligible individuals include those over sixty-five, individuals receiving Social Security disability benefits, and those under sixty-five receiving dialysis.
Medicare Part A is also referred to as hospital insurance.
Most individuals eligible for Medicare Part A do not pay a premium if they or their spouse have forty quarters of Medicare-covered employment.

Enrollment and Premiums

If enrollment in Part B exceeds twelve months after the initial enrollment period, a 10% premium increase occurs for each year of delay.
Medicare beneficiaries may receive benefits under the affordable Medicare Advantage plans, combining various services.

Medicare Parts Overview

Medicare Part B covers medical equipment, medical supplies, and physician services, among other benefits.
Coinsurance for physicians' services under Part B is 20%.
Medicare Part D provides prescription drug coverage.

Legislation and Reform

The Medicare Modernization Act was enacted in 2003, introducing improvements such as better benefits for Part C enrollees.
Federal legislation determines services covered under Medicare, including guidelines for claims.

Claims and Billing Procedures

Medicare administrative contractors manage claims for Parts A and B.
Providers in Health Professional Shortage Areas (HPSAs) receive a 10% bonus payment from Medicare.
Providers can bill patients for non-covered services under a written notification noted as a voluntary ABN.

Coverage Exclusions and Limitations

Services excluded from Medicare include acupuncture, eye refraction, and self-administered medications.
NonPAR providers may charge patients up to 115% of the fee listed in the nonPAR MFS under the limiting charges clause.

Supplemental Insurance and Payment Arrangements

Medigap plans help cover expenses such as deductibles and coinsurance that Medicare does not fully cover.
PAR providers must accept charge amounts listed in the Medicare Physician Fee Schedule as their total payment.

Administrative Guidance and Patient Information

ABN forms are crucial for informing patients about potential costs and services not covered by Medicare.
Relevant sections of ABN forms include the Header, Body, and Options Box, which indicate what services may not be covered.

Audit and Compliance

The Medicare Integrity Program aims to identify and tackle fraud, waste, and abuse.
Timely filing limits for claims have changed under the Affordable Care Act, requiring filing within one calendar year after service.

Miscellaneous

All Medicare beneficiaries are eligible for services from Medicare-approved providers under various plans.
Services of allied health professionals billed under direct supervision are termed incident-to services.
When both covered and noncovered services are performed on the same date, practices must split the bill for appropriate billing.

Vaccinations and Billing Practices

Medicare covers vaccinations for influenza and pneumococcal diseases, and claims do not need to be sent electronically.### Medicare Coverage and Claims Processing
Vaccinations for influenza and pneumococcal are covered by Medicare without requiring annual Part B deductibles.
Claims for these vaccinations can be submitted non-electronically.

Clinical Laboratory Regulations

All lab work for Medicare patients is governed by Clinical Laboratory Improvement Amendments (CLIA) rules.

Medicare Assignment Code

The Medicare assignment code "C" indicates that the assignment is not assigned.

Insurance Type Code Requirements

An insurance type code is required when a claim is sent to Medicare while Medicare is not the primary payer.

Incident-to Services Providers

Incident-to services can be performed by physician assistants and nurse-practitioners.

Medigap and Medicare Claims

Medicare automatically sends claims to a Medigap plan for secondary payment if the patient has both Medicare and Medigap coverage.

Simplified Billing for Vaccines

Roster billing is a simplified process used for the billing of vaccines.

Timely Filing for Part B Claims

Claims for Part B providers must be filed within one calendar year after the date of service as per the Affordable Care Act.

Medicare Assignment Code Identification

The Medicare assignment code "A" signifies that the provider accepts Medicare assignment.

Primary Payer Identification

The insurance type code "AP" is utilized to identify an auto insurance policy as the primary payer.

Medicare Claims Submitted by Patients with Medigap

Only one claim is sent to Medicare when a patient is covered by both Medicare and a Medigap plan.

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Description

This quiz covers key concepts from Chapter 9 related to the Medicare program. Test your knowledge on the administration, eligibility, and specifics of Medicare benefits. Prepare to identify the correct agency and understand who qualifies for these healthcare services.