Questions and Answers
When was the Medicare program established?
1965
What does Medicare Part A pay for?
Hospital/Facility care
What does Medicare Part B pay for?
Physicians services and durable medical equipment
Who handles the day-to-day operation of the Medicare program for the CMS?
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What percentage of covered charges does Medicare pay?
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What is the incentive for Medicare participating providers?
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What are Part B services billed using?
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Who is the largest third party payer in the nation?
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In what year did a major change take place in Medicare with the enactment of the Omnibus Budget Reconciliation Act?
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What components make up the physician's fee schedule?
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What percentage does Medicare pay for multiple procedures performed by the same surgeon on the same day?
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Medicare sets the payment level for assistant surgeons at a percentage of the fee schedule amount for what surgical service?
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What edition of the Federal Register would outpatient facilities be especially interested in?
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What edition of the Federal Register would hospital facilities be especially interested in?
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What are the three items Medicare beneficiaries are responsible to pay before Medicare will begin to pay for services?
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Who collects Medicare funds?
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CMS handles the daily operation of the Medicare program through the use of what?
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Limiting provider liabilities is a stated goal of the Physician Payment Reform.
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If a QIO provider renders a covered service that costs $100 and bills Medicare for the service which allowed $58, what amount would the provider bill the patient?
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What benefits were established under the Medicare Prescription Drug, Improvement and Modernization Act of 2003?
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What is Medicare Advantage also known as?
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__________ are activities involving the transfer of health care information and______ means the movement of electronic data between two entities.
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What does CMS stand for?
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What does QIO stand for?
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What does RBRVS stand for?
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What does OBRA stand for?
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What does MAAC stand for?
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What does RVU stand for?
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What does OIG stand for?
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Study Notes
Medicare Overview
- Established in 1965 to provide health coverage for older adults and certain disabled individuals.
Medicare Parts
- Part A: Covers hospital and facility care.
- Part B: Covers physician services and durable medical equipment.
- Part C: Known as Medicare Advantage, combining A and B with additional benefits.
- Part D: Offers prescription drug coverage, established by the Medicare Prescription Drug, Improvement and Modernization Act of 2003.
Administration and Operations
- Daily operations managed by Medicare Administrative Contractors (MACs), formerly known as fiscal intermediaries.
- The Centers for Medicare and Medicaid Services (CMS) establishes regulations and oversees operations.
Payment Structure
- Medicare reimburses 80% of covered charges after deductibles and coinsurance.
- Physicians' fee schedule updated annually on April 15, involving relative value units, geographic adjustment, and conversion factors.
- Assistant surgeons are paid a percentage of the global surgical fee schedule.
Billing and Charges
- Part B services billed using ICD-9-CM, CPT, and HCPCS coding.
- If a provider bills for multiple procedures on the same day, Medicare pays: 100% for the first, 50% for subsequent procedures.
- Patients billed $0 when a Quality Improvement Organization (QIO) provider charges less than the allowed amount.
Beneficiary Responsibilities
- Medicare beneficiaries must pay deductibles, premiums, and coinsurance before coverage starts.
Quality Improvement
- Quality Improvement Organizations (QIOs) monitor healthcare quality, previously known as Peer Review Organizations (PROs).
Regulatory Changes
- Significant changes to Medicare enacted in 1989 through the Omnibus Budget Reconciliation Act (OBRA), which updated standards and introduced fee schedules.
Payment Reforms
- Resource Based Relative Value Scale (RBRVS) aims to equitably redistribute physician payments and reduce Medicare expenditures while ensuring quality healthcare.
Important Definitions
- MAAC: Maximum Actual Allowable Charge, limits on charges from non-participating physicians.
- RVU: Relative Value Unit, assesses work, overhead costs, and malpractice expenses for services.
- OIG: Office of the Inspector General, responsible for Medicare oversight and compliance.
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Description
This quiz consists of flashcards that cover the key concepts from Chapter 1 of the Step by Step Medicare guide. It explores important details about the Medicare program, including its establishment, coverage parts, and operational management. Perfect for students or anyone looking to refresh their knowledge on Medicare basics.
