Medicare Overview and Benefits

Medicare was established in 1965 to provide health insurance for Americans aged 65 and older, later expanding to younger individuals with disabilities and certain diseases.

Eligibility for Medicare includes individuals aged 65 or older, younger individuals with disabilities, and people with End-Stage Renal Disease or ALS.

Key information includes the beneficiary's name, Medicare number, coverage dates, and plan type.

<p>Medicare provides health insurance coverage that includes hospital care, medical services, and preventive services.</p> Signup and view all the answers

<ol> <li>Medicare Modernization Act, 2. Older Americans Act, 3. Affordable Care Act, 4. Employee Retirement Income Security Act, 5. Consolidated Omnibus Budget Reconciliation Act.</li> </ol> Signup and view all the answers

<p>Medicare programs include Parts A (Hospital Insurance), B (Medical Insurance), C (Medicare Advantage), and D (Prescription Drug Coverage).</p> Signup and view all the answers

<p>The program is called the Quality Improvement Organization (QIO).</p> Signup and view all the answers

<p>Participating providers agree to accept Medicare-approved amounts, while nonparticipating providers may charge higher fees and can balance-bill patients.</p> Signup and view all the answers

<p>The two types are Original Medicare (Parts A and B) and Medicare Advantage Plans (Part C).</p> Signup and view all the answers

<p>A patient's signature is required before providing services that may not be covered by Medicare.</p> Signup and view all the answers

<p>Noncovered services include cosmetic procedures, routine dental care, and long-term care.</p> Signup and view all the answers

<p>A prepayment screen is an edit implemented to prevent payment for noncovered or incorrectly coded services.</p> Signup and view all the answers

<p>Payment methodologies include fee-for-service, prospective payment system, and value-based payment models.</p> Signup and view all the answers

<p>This system ranks services based on the resources required for each service to determine payment rates.</p> Signup and view all the answers

<p>This act transitioned Medicare reimbursement from volume-based to value-based care, emphasizing quality over quantity.</p> Signup and view all the answers

<p>Claims must be submitted within one calendar year from the date of service.</p> Signup and view all the answers

<p>A Medicare Administrative Contractor (MAC) processes Medicare claims and manages enrollment for providers.</p> Signup and view all the answers

<p>The time limit is generally one calendar year from the date of service.</p> Signup and view all the answers

<p>Components include patient information, services billed, payment determination, and any patient responsibility.</p> Signup and view all the answers

<p>Identifying overpayments is crucial for compliance and may require repayment to Medicare.</p> Signup and view all the answers

<p>Adjudication is the process by which an insurance company determines the outcome of a claim.</p> Signup and view all the answers

<p>An adjustment is any change to the balance due of an account, such as an overpayment or write-off.</p> Signup and view all the answers

<p>An ABN is a notice given to patients to inform them that Medicare may not cover a service.</p> Signup and view all the answers

<p>APM is a reimbursement model that incentivizes high-quality, cost-efficient healthcare delivery.</p> Signup and view all the answers

<p>CCI is legislation aimed at preventing inappropriate reporting of procedural codes.</p> Signup and view all the answers

<p>CMS is the federal agency responsible for administering the Medicare program.</p> Signup and view all the answers

<p>DC commonly stands for 'Doctor of Chiropractic' or 'Discharge' in healthcare.</p> Signup and view all the answers

<p>DME refers to equipment that provides therapeutic benefits to patients with certain medical conditions.</p> Signup and view all the answers

<p>ERA is an electronic version of the remittance advice detailing payment information.</p> Signup and view all the answers

<p>ESRD is the final stage of chronic kidney disease, where kidneys can no longer function.</p> Signup and view all the answers

<p>GPCIs are adjustments made to payments based on geographic differences in practice costs.</p> Signup and view all the answers

<p>ICU is a specialized section of a hospital that provides intensive treatment and monitoring.</p> Signup and view all the answers

<p>LCDs are decisions made by Medicare contractors about the coverage of specific services.</p> Signup and view all the answers

<p>LGHP refers to an employer-sponsored health plan that covers a significant number of employees.</p> Signup and view all the answers

<p>Medicare Advantage Plans are private insurance options offering Medicare benefits.</p> Signup and view all the answers

<p>A MAC processes claims, manages enrollment, and provides customer service for Medicare.</p> Signup and view all the answers

<p>MACRA is legislation aimed at improving Medicare reimbursement and reducing costs.</p> Signup and view all the answers

<p>The MBI is an 11-character identifier used on Medicare cards for beneficiary identification.</p> Signup and view all the answers

<p>The manual provides guidelines for billing and claims submission for healthcare providers.</p> Signup and view all the answers

<p>The fee schedule lists the predetermined amounts Medicare will pay for specific services.</p> Signup and view all the answers

<p>This act includes provisions for enhancing benefits and supports for older adults.</p> Signup and view all the answers

<p>A Medicare/Medicaid recipient is an individual who qualifies for both Medicare and Medicaid benefits.</p> Signup and view all the answers

<p>Part A covers hospital insurance, including inpatient care and certain skilled nursing services.</p> Signup and view all the answers

<p>Part B covers medical insurance, including outpatient care and preventive services.</p> Signup and view all the answers

<p>Part C, or Medicare Advantage, offers additional coverage through private insurers.</p> Signup and view all the answers

<p>Part D is a prescription drug coverage plan provided through private insurance companies.</p> Signup and view all the answers

<p>It refers to the insurance that pays for services after Medicare has made its payment.</p> Signup and view all the answers

<p>It is a document explaining the services billed, payment amounts, and patient responsibilities.</p> Signup and view all the answers

<p>Medigap is a supplemental insurance policy that helps cover costs not included in Medicare.</p> Signup and view all the answers

<p>MIPS is a program that adjusts payments to providers based on the quality of care they deliver.</p> Signup and view all the answers

<p>It provides guidelines that determine whether a service is covered at the federal level.</p> Signup and view all the answers

<p>It is a system that provides healthcare coverage for all citizens, typically funded by the government.</p> Signup and view all the answers

<p>A national provider identifier is a unique identifier assigned to healthcare providers for billing purposes.</p> Signup and view all the answers

<p>A nonparticipating provider does not have a contract with Medicare and may bill higher rates.</p> Signup and view all the answers

<p>A nursing facility, or skilled nursing facility, provides 24-hour care and rehabilitative services.</p> Signup and view all the answers

<p>A participating provider has a contract with Medicare and agrees to accept its payment terms.</p> Signup and view all the answers

<p>A premium is the amount paid for insurance coverage, typically billed monthly or annually.</p> Signup and view all the answers

<p>A prepayment screen refers to edits used to identify incorrect billing before payments are made.</p> Signup and view all the answers

<p>A prospective payment system sets fixed rates for Medicare services based on diagnosis.</p> Signup and view all the answers

<p>A QIO monitors and improves the quality of care provided to Medicare beneficiaries.</p> Signup and view all the answers

<p>This initiative aims to recover overpayments made by Medicare due to billing errors.</p> Signup and view all the answers

<p>Remittance advice is a document sent by an insurer to providers detailing payment determinations.</p> Signup and view all the answers

<p>This scale ranks physician services based on the resources required to perform them.</p> Signup and view all the answers

<p>Respite care provides temporary relief for caregivers of terminally ill patients.</p> Signup and view all the answers

<p>SSI is a program providing financial assistance to low-income individuals who are aged or disabled.</p> Signup and view all the answers

<p>Value-based programs reward healthcare providers for delivering quality, efficient care.</p> Signup and view all the answers