Medicare Key Terms and Concepts

Questions and Answers

What is a benefit period?

Time during which medical benefits are available to insurance beneficiaries.

What does the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provide?

Temporary continuation of health coverage for 18 months after an appointment has ended.

What does a crossover refer to in Medicare?

Reassignment of gaps in coverage to eliminate the need for beneficiaries to file a separate claim with their medigap insurer.

What is end-stage renal disease (ESRD)?

Total or nearly complete failure of the kidney. Signup and view all the answers

What is an electronic remittance advice (ERA)?

Electronic notification sent to the provider who accepts assignment. Signup and view all the answers

Who are intermediaries in the context of Medicare?

The private company that has a contract with Medicare to pay Part A and some Part B bills. Signup and view all the answers

What is a limiting charge?

The maximum amount nonparticipating providers can charge the Medicare patient on a non-assignment claim. Signup and view all the answers

What does local coverage determination (LCDs) refer to?

A decision by Medicare, a carrier, or intermediary as to whether the service is reasonable or necessary. Signup and view all the answers

What qualifies as Medicare abuse?

Improper payment for items or services when there was no legal entitlement to the payment. Signup and view all the answers

What is Medicare Advantage (MA)?

An option that offers extended benefits for a fee through private health insurance programs. Signup and view all the answers

What is a Medicare administrative contractor (MAC)?

Contractors awarded contract by CMS to adjudicate and pay Medicare claims. Signup and view all the answers

What is a Medicare development letter?

A letter sent to a provider by Medicare requesting additional information or documentation for the processing of a claim. Signup and view all the answers

What is medical fraud?

Knowingly and intentionally executing a plan to scheme or defraud any healthcare benefits program. Signup and view all the answers

What does Medicare Part A cover?

Hospital fees for the elderly, individuals with disabilities, and people with end-stage renal disease. Signup and view all the answers

What services are covered under Medicare Part B?

Physician services, outpatient hospital care, durable medical equipment, and some services not covered by Part A. Signup and view all the answers

What is Medicare Part C?

Offers extended benefits for a fee through private health insurance programs that contract with Medicare. Signup and view all the answers

What is Medicare Part D?

Medicare prescription drug coverage program. Signup and view all the answers

What is a medical remittance notice (MRN)?

Notice provided by Medicare contractors on assigned claims detailing how to explain the claims process. Signup and view all the answers

What is a Medicare secondary payer (MSP)?

Any situation in which a payer is required by federal law to pay before Medicare pays. Signup and view all the answers

What is a Medicare summary notice (MSN)?

An easy-to-read document that clearly lists the health insurance claim information and details of services rendered. Signup and view all the answers

What is Medigap?

A privately purchased Medicare supplemental health insurance policy designed to provide additional coverage. Signup and view all the answers

What is the meaning of Non-par MFS?

Amount that applies to unassigned services performed by physicians and suppliers who choose not to participate in Medicare. Signup and view all the answers

What is the role of the Office of Inspector General (OIG)?

To combat fraud, waste, and abuse and to improve the efficiency of Health and Human Services. Signup and view all the answers

What does PACE stand for?

Programs of all-inclusive care for the elderly. Signup and view all the answers

What is a Recovery Audit Contractor (RAC)?

An organization that audits processed claims to identify and recover improper payments. Signup and view all the answers

What is scrubbing in the context of claims processing?

Cleaning of the claim by a clearinghouse before submission to ensure data is entered correctly. Signup and view all the answers

What does the Tax Relief and Health Care Act (TRHCA) emphasize?

Commitment to renewable energy resources and making health insurance more affordable for Americans, especially farmers and small businesses. Signup and view all the answers

What are the three roles of CMS?

<ol> <li>Establishing policy for the reimbursement of providers, 2. Conducting research into healthcare management and treatment, 3. Assessing the quality of healthcare facilities and services.</li> </ol> Signup and view all the answers

Study Notes

Medicare Key Terms and Concepts

Benefit Period: Duration medical benefits are available to insurance beneficiaries.
COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985): Allows temporary health coverage continuation for 18 months after employment ends.
Crossover: Process that eliminates the need for beneficiaries to file separate claims with Medigap insurers by reassessing coverage gaps.
End-Stage Renal Disease (ESRD): A condition marked by total or nearly complete kidney failure.
Electronic Remittance Advice (ERA): Digital notification sent to providers confirming payment acceptance of claims.
Intermediaries: Private companies contracted by Medicare to process and pay certain Part A and Part B medical bills.
Limiting Charge: Maximum fee non-participating providers can charge Medicare patients for non-assignment claims.
Local Coverage Determination (LCDs): Decisions by Medicare intermediaries on the reasonable or necessary nature of specific services.
Medicare Abuse: Involves improper payments for services or items lacking legal entitlement.
Medicare Advantage (MA): Offers extended benefits through private health insurance plans like HMOs and PPOs under Medicare's regulations.
Medicare Administrative Contract (MAC): Entities awarded contracts by CMS to handle claim adjudication and payments, previously known as fiscal intermediaries.
Medicare Development Letter: Communication sent to providers for additional documentation during claim processing.
Medical Fraud: Intentional schemes to defraud healthcare benefit programs for financial gain.
Medicare Part A: Covers hospital expenses for the elderly, disabled individuals, and those with ESRD.
Medicare Part B: Contributes to physician services, outpatient care, durable medical equipment, and select services not covered by Part A.
Medicare Part C: Another name for Medicare Advantage, providing extended benefits through contracted private insurance programs.
Medicare Part D: Program focused on prescription drug coverage.
Medical Remittance Notice (MRN): Details provided by Medicare contractors on assigned claims, outlining the claims process.
Medicare Secondary Payer (MSP): Any instance requiring another payer to settle claims before Medicare's involvement.
Medicare Summary Notice (MSN): Reader-friendly document listing health insurance claim details and services provided.
Medigap: Private supplemental health insurance policies to cover gaps in Medicare coverage.
Non-par MFS: Amount applied to unassigned services from physicians and suppliers opting out of Medicare participation.
Office of Inspector General (OIG): Federal entity focused on fighting healthcare fraud, waste, and abuse, improving Health and Human Services efficiency.
Programs of All-Inclusive Care for the Elderly (PACE): Medicare-Medicaid hybrid program providing at-home long-term care services.
Recovery Audit Contractor (RAC): Audits processed claims for coverage accuracy and identifies overpaid claims.
Scrubbing: Process of ensuring claims data is accurate and cleaned prior to submission by a clearinghouse.
Tax Relief and Healthcare Act (TRHCA): Aims to facilitate access to health insurance and promote renewable energy resources for Americans.
Roles of CMS: Establishing reimbursement policies, researching healthcare management and treatments, and assessing healthcare quality.

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Description

Test your knowledge of essential Medicare terminologies and concepts. This quiz covers various key terms such as benefit periods, COBRA, and electronic remittance advice, helping you understand the complexities of Medicare and its provisions. Ideal for students or professionals in the healthcare field.