Podcast
Questions and Answers
What legislative act allowed billing approval for nonphysician practitioners like NPs?
What legislative act allowed billing approval for nonphysician practitioners like NPs?
What percentage of the fee schedule rate is used for payments to NPs by CMS?
What percentage of the fee schedule rate is used for payments to NPs by CMS?
What is the primary requirement for Medicare providers when submitting claims?
What is the primary requirement for Medicare providers when submitting claims?
Which type of healthcare service does Medicare Part A primarily cover?
Which type of healthcare service does Medicare Part A primarily cover?
Signup and view all the answers
What is the copayment amount for beneficiaries in a skilled nursing facility after 20 days?
What is the copayment amount for beneficiaries in a skilled nursing facility after 20 days?
Signup and view all the answers
Which of the following statements is true regarding lifetime reserved days under Medicare?
Which of the following statements is true regarding lifetime reserved days under Medicare?
Signup and view all the answers
How are Medicare premiums calculated?
How are Medicare premiums calculated?
Signup and view all the answers
What happens to all costs incurred beyond the lifetime reserve days?
What happens to all costs incurred beyond the lifetime reserve days?
Signup and view all the answers
What are considered third-party payers for healthcare services?
What are considered third-party payers for healthcare services?
Signup and view all the answers
Which part of Medicare covers hospital inpatient services?
Which part of Medicare covers hospital inpatient services?
Signup and view all the answers
What is the reimbursement rate for nurse practitioners billing under CMS guidelines?
What is the reimbursement rate for nurse practitioners billing under CMS guidelines?
Signup and view all the answers
What is the Medicare Part A hospital deductible for the year 2021?
What is the Medicare Part A hospital deductible for the year 2021?
Signup and view all the answers
Which of the following does NOT fall under the category of third-party payers?
Which of the following does NOT fall under the category of third-party payers?
Signup and view all the answers
What is required for providers to bill Medicare for their services?
What is required for providers to bill Medicare for their services?
Signup and view all the answers
How is the copayment structured for skilled nursing facility (SNF) postacute care from days 21 to 100?
How is the copayment structured for skilled nursing facility (SNF) postacute care from days 21 to 100?
Signup and view all the answers
Which of the following is a characteristic of Managed Care Organizations (MCOs)?
Which of the following is a characteristic of Managed Care Organizations (MCOs)?
Signup and view all the answers
What percentage of the physician's fee schedule do nurse practitioners receive as reimbursement from CMS?
What percentage of the physician's fee schedule do nurse practitioners receive as reimbursement from CMS?
Signup and view all the answers
What is the coinsurance amount for hospital stays beyond 90 days in a benefit period?
What is the coinsurance amount for hospital stays beyond 90 days in a benefit period?
Signup and view all the answers
Which piece of legislation allowed billing approval for nonphysician practitioners like nurse practitioners?
Which piece of legislation allowed billing approval for nonphysician practitioners like nurse practitioners?
Signup and view all the answers
Which of the following statements about private pay patients is true?
Which of the following statements about private pay patients is true?
Signup and view all the answers
Which of the following correctly describes the patient’s responsibility for coverage under Medicare B?
Which of the following correctly describes the patient’s responsibility for coverage under Medicare B?
Signup and view all the answers
What was the annual deductible for Medicare B in the year 2021?
What was the annual deductible for Medicare B in the year 2021?
Signup and view all the answers
Which days of a hospital stay incur no additional payment for beneficiaries under Medicare A?
Which days of a hospital stay incur no additional payment for beneficiaries under Medicare A?
Signup and view all the answers
What percentage of the physician fee schedule is reimbursed to CMS-covered physicians?
What percentage of the physician fee schedule is reimbursed to CMS-covered physicians?
Signup and view all the answers
What percentage of the allowed rate does CMS pay for services covered by the physician fee schedule?
What percentage of the allowed rate does CMS pay for services covered by the physician fee schedule?
Signup and view all the answers
What is the Medicare B deductible for the year 2021?
What is the Medicare B deductible for the year 2021?
Signup and view all the answers
Which of the following is true regarding the reimbursement rates for Nurse Practitioners (NPs)?
Which of the following is true regarding the reimbursement rates for Nurse Practitioners (NPs)?
Signup and view all the answers
What is the recommended practice regarding patient out-of-pocket payments before providing services?
What is the recommended practice regarding patient out-of-pocket payments before providing services?
Signup and view all the answers
What is one reason for collecting copayment and deductible payments before services are rendered?
What is one reason for collecting copayment and deductible payments before services are rendered?
Signup and view all the answers
What is the typical monthly premium cost for a secondary insurance plan for Medicare beneficiaries?
What is the typical monthly premium cost for a secondary insurance plan for Medicare beneficiaries?
Signup and view all the answers
Which of the following is NOT a component of patient out-of-pocket expenses under Medicare?
Which of the following is NOT a component of patient out-of-pocket expenses under Medicare?
Signup and view all the answers
What administrative strategy did the physician fee schedule aim to achieve?
What administrative strategy did the physician fee schedule aim to achieve?
Signup and view all the answers
What is the primary focus of Title I of HIPAA?
What is the primary focus of Title I of HIPAA?
Signup and view all the answers
Which of the following interventions is classified as primary prevention?
Which of the following interventions is classified as primary prevention?
Signup and view all the answers
What does Title II of HIPAA primarily address?
What does Title II of HIPAA primarily address?
Signup and view all the answers
Which of the following is a component of tertiary prevention?
Which of the following is a component of tertiary prevention?
Signup and view all the answers
How does HIPAA legislation contribute to the management of healthcare practices?
How does HIPAA legislation contribute to the management of healthcare practices?
Signup and view all the answers
Which example represents secondary prevention?
Which example represents secondary prevention?
Signup and view all the answers
What is one key aspect of primary prevention strategies?
What is one key aspect of primary prevention strategies?
Signup and view all the answers
What financial impact is associated with states that accept Medicaid expansion?
What financial impact is associated with states that accept Medicaid expansion?
Signup and view all the answers
What percentage of the discounted rate do beneficiaries pay for brand drugs during the coverage gap phase?
What percentage of the discounted rate do beneficiaries pay for brand drugs during the coverage gap phase?
Signup and view all the answers
Which phase does not require beneficiaries to pay any costs before meeting the deductible?
Which phase does not require beneficiaries to pay any costs before meeting the deductible?
Signup and view all the answers
What is a potential disadvantage of Medicare Advantage (MA) plans for beneficiaries?
What is a potential disadvantage of Medicare Advantage (MA) plans for beneficiaries?
Signup and view all the answers
How do Medicare Advantage carriers receive payment for the services they provide?
How do Medicare Advantage carriers receive payment for the services they provide?
Signup and view all the answers
What major policy change was included in the ACA regarding the donut hole?
What major policy change was included in the ACA regarding the donut hole?
Signup and view all the answers
Which of the following statements is true about the financial viability of Medicare Advantage plans?
Which of the following statements is true about the financial viability of Medicare Advantage plans?
Signup and view all the answers
What is one reason many Medicare Advantage carriers might exit the market?
What is one reason many Medicare Advantage carriers might exit the market?
Signup and view all the answers
What is the role of the initial coverage phase in the Medicare drug coverage structure?
What is the role of the initial coverage phase in the Medicare drug coverage structure?
Signup and view all the answers
What must a healthcare provider obtain in order to bill Medicare services?
What must a healthcare provider obtain in order to bill Medicare services?
Signup and view all the answers
Which statement accurately describes the payment structure for hospital stays under Medicare A?
Which statement accurately describes the payment structure for hospital stays under Medicare A?
Signup and view all the answers
Which type of Medicare Advantage plan includes a network of providers that members must use for their healthcare services?
Which type of Medicare Advantage plan includes a network of providers that members must use for their healthcare services?
Signup and view all the answers
What is the primary purpose of the federal funding in the Medicaid program?
What is the primary purpose of the federal funding in the Medicaid program?
Signup and view all the answers
What is the maximum coinsurance amount for a Medicare patient who has used their lifetime reserve days?
What is the maximum coinsurance amount for a Medicare patient who has used their lifetime reserve days?
Signup and view all the answers
Which income eligibility method was established by the ACA for Medicaid?
Which income eligibility method was established by the ACA for Medicaid?
Signup and view all the answers
What regulatory body is responsible for the authority over Advanced Practice Registered Nurses (APRNs)?
What regulatory body is responsible for the authority over Advanced Practice Registered Nurses (APRNs)?
Signup and view all the answers
How are payments structured for nurse practitioners under CMS billing rules during 2021?
How are payments structured for nurse practitioners under CMS billing rules during 2021?
Signup and view all the answers
Which groups are specifically exempt from meeting the MAGI requirements for Medicaid eligibility?
Which groups are specifically exempt from meeting the MAGI requirements for Medicaid eligibility?
Signup and view all the answers
What is a primary requirement for a healthcare provider in order to accept Medicare assignments?
What is a primary requirement for a healthcare provider in order to accept Medicare assignments?
Signup and view all the answers
What is a significant condition that must be met for Medicaid payments to providers?
What is a significant condition that must be met for Medicaid payments to providers?
Signup and view all the answers
What type of hospital payment applies to facilities that care for a disproportionate share of Medicaid-eligible patients?
What type of hospital payment applies to facilities that care for a disproportionate share of Medicaid-eligible patients?
Signup and view all the answers
What happens if a Medicare beneficiary exceeds the lifetime reserved days for hospital stays?
What happens if a Medicare beneficiary exceeds the lifetime reserved days for hospital stays?
Signup and view all the answers
What is the out-of-pocket expense for a beneficiary in a skilled nursing facility after 100 days?
What is the out-of-pocket expense for a beneficiary in a skilled nursing facility after 100 days?
Signup and view all the answers
How does the federal government support state spending on qualifying Medicaid services?
How does the federal government support state spending on qualifying Medicaid services?
Signup and view all the answers
What change has occurred in the enrollment process for Medicaid and CHIP in recent years?
What change has occurred in the enrollment process for Medicaid and CHIP in recent years?
Signup and view all the answers
What is the primary impact of the U.S. Supreme Court ruling on ACA Medicaid expansion?
What is the primary impact of the U.S. Supreme Court ruling on ACA Medicaid expansion?
Signup and view all the answers
Which of the following categories is NOT included in the general categories of third-party payers?
Which of the following categories is NOT included in the general categories of third-party payers?
Signup and view all the answers
How does Medicaid expansion generally affect the quality of care in participating states?
How does Medicaid expansion generally affect the quality of care in participating states?
Signup and view all the answers
What role do the Centers for Medicare and Medicaid Services (CMS) guidelines play for third-party payers?
What role do the Centers for Medicare and Medicaid Services (CMS) guidelines play for third-party payers?
Signup and view all the answers
Which of the following best explains the consequences of states not accepting Medicaid expansion funds?
Which of the following best explains the consequences of states not accepting Medicaid expansion funds?
Signup and view all the answers
What economic impact is generally observed in states that accept Medicaid expansion?
What economic impact is generally observed in states that accept Medicaid expansion?
Signup and view all the answers
What is the primary reason for the political opposition to Medicaid expansion under the ACA?
What is the primary reason for the political opposition to Medicaid expansion under the ACA?
Signup and view all the answers
In what context do APRNs demonstrate cost savings compared to traditional providers?
In what context do APRNs demonstrate cost savings compared to traditional providers?
Signup and view all the answers
What is the maximum out-of-pocket limit for in-network services under Medicare Advantage plans in 2024?
What is the maximum out-of-pocket limit for in-network services under Medicare Advantage plans in 2024?
Signup and view all the answers
Which of the following Medicare parts does NOT require a monthly premium in some plans?
Which of the following Medicare parts does NOT require a monthly premium in some plans?
Signup and view all the answers
What is the deductible amount for Medicare Part B in 2024?
What is the deductible amount for Medicare Part B in 2024?
Signup and view all the answers
Study Notes
Third-Party Payer Rules
- Reimbursement policies for NPs depend on third-party payers, which include Medicare, Medicaid, indemnity insurance, managed care organizations, workers' compensation, Veterans Administration, and auto liability.
- Patients without health insurance are considered private pay, while those who can afford it may pay out of pocket.
- All payer sources adhere to CMS guidelines, which aim to ensure high-quality health care for beneficiaries of government-funded programs.
Medicare Overview
- Medicare comprises four parts: A (hospital services), B (physician services), C (Medicare Advantage Plans), and D (prescription drug coverage).
- Medicare providers must apply via PECOS or CMS-855I and are assigned an NPI for billing in HIPAA transactions.
- Providers must accept CMS-approved amounts as full payment and file claims for all services.
Medicare Part A (Hospital Inpatient Services)
- In 2021, the deductible was $1,484 with no additional payment required for the first 60 days of a hospital stay.
- From days 61 to 90, a coinsurance of 371perdayapplies;beyond90days,alifetimereservedaychargeof371 per day applies; beyond 90 days, a lifetime reserve day charge of 371perdayapplies;beyond90days,alifetimereservedaychargeof742 is incurred.
- After 20 days in skilled nursing facilities, beneficiaries must pay a copayment of $185.50 per day.
Medicare Part B (Physician Services)
- NPs receive 85% of the physician fee schedule, with patients covering 20% of approved rates.
- The deductible for Medicare B was $203 in 2021, with secondary insurance commonly used to cover out-of-pocket expenses.
- Each year, the physician fee schedule is updated to reflect reimbursement policies aimed at enhancing accessibility and quality.
Patient Payment Responsibilities
- Patients often need to meet deductibles and copayments prior to receiving services.
- Best practice encourages collection of these payments ahead of treatment to minimize billing expenses.
- CMS emphasizes the importance of verifying patient payment responsibilities at each treatment visit.
Medicaid
- States accepting Medicaid expansion have experienced positive economic impacts due to increased federal funds.
Health Insurance Portability and Accountability Act (HIPAA)
- Title I protects health insurance for workers during job transitions, while Title II streamlines administrative processes in healthcare.
- HIPAA mandates security considerations for electronic health data, ensuring providers take precautions for patient information security.
Prevention Strategies
- Primary Prevention: Focuses on immunizations, health education, and lifestyle choices, such as weight control and seat belt use.
- Secondary Prevention: Involves screenings for various health conditions, such as cancers and diabetes.
- Tertiary Prevention: Concentrates on treatments aimed at preventing complications from existing diseases.
Concept of Prevention Levels
- Primary, secondary, and tertiary prevention represent distinct approaches to health promotion and disease prevention, each targeting different stages of health intervention.
Medicare Overview
- Medicare reimburses 85% for services covered by Nurse Practitioners (NP) with National Provider Identifiers (NPI).
- Reimbursement sources include managed care plans (HMO/PPO), Medicaid, Medicare, concierge services, and COBRA.
Medicare Parts A, B, C, and D
-
Medicare A: Covers inpatient hospital stays and skilled nursing care; has no premium for most beneficiaries. Requires 20% co-pay; no annual limit on out-of-pocket expenses.
-
Medicare B: Covers outpatient services; involves a monthly premium of 174.70(2024)alongwithaseparatedeductibleof174.70 (2024) along with a separate deductible of 174.70(2024)alongwithaseparatedeductibleof240. Medicare pays 80% of covered costs after meeting the deductible.
-
Medicare C (Medicare Advantage Plans): Private-managed Medicare combining A & B with varying co-payment structures. Offers added benefits like drug coverage, vision, and dental. In 2024, the out-of-pocket limits are 8,850(in−network)and8,850 (in-network) and 8,850(in−network)and13,300 (combined).
-
Medicare D: Focuses on prescription drugs. Monthly premium is 36.78(2024)witha36.78 (2024) with a 36.78(2024)witha2,000 out-of-pocket cap for drug spending.
Deductible Overview for 2024
- Medicare Part A: $1,632
- Medicare Part B: $240
- Medicare Part D: $545
Gaps in Original Medicare
- Original Medicare does not cover routine vision, hearing exams, or Part D drugs.
- Many beneficiaries choose Medicare Supplement or HMO plans to cover these gaps; average Medigap cost is around $150/month.
Pharmaceutical Costs and Coverage Phases
- Prescription costs vary significantly; beneficiary premiums range from 12to12 to 12to195/month.
- Cost structure consists of four phases:
- Deductible phase
- Initial coverage phase (co-pays apply)
- Coverage gap (25% of brand drug discounted rates)
- Catastrophic phase (5% copay discount)
Medicare Advantage Plans
- Offer comprehensive service coverage including A & B., while providing additional benefits like drug coverage and lower co-payments.
- Must use participating providers; designed to achieve lower costs through volume discounts.
- Issues arise from high utilization and costs leading to many plans exiting the market.
Types of Medicare Advantage Plans
- Health Maintenance Organization (HMO)
- Preferred Provider Organization (PPO)
- Private Fee-for-Service (PFFS)
- Special Needs Plans (SNPs)
Medicaid Overview
- Provides medical assistance for low-income individuals and families, particularly children, pregnant women, and those with disabilities.
- Funded jointly by federal and state governments; eligibility criteria include Modified Adjusted Gross Income (MAGI).
- Medicaid and CHIP provided coverage for over 72.5 million Americans in 2020.
Medicaid Enhancement and Challenges
- Federal government matches state dollar spending for mandatory services; reimbursement rates must attract sufficient providers.
- No significant changes to the system have been enacted despite discussions; ACA has positively influenced enrollment processes.
Third-Party Payer Rules
- Seven categories define third-party payers, including Medicare, Medicaid, and indemnity insurance.
- NPs’ reimbursement policies are determined by these third-party payers; they follow CMS guidelines.
Billing and Reimbursement for Medicare
- Providers can enroll to bill Medicare via PECOS or traditional forms. Each provider receives an NPI for billing.
- Reimbursement relies on claims submitted to CMS based on services rendered, with specific guidelines for coverage, deductibles, and co-pays.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Related Documents
Description
Test your knowledge on the rules and regulations regarding third-party payers in healthcare. This quiz covers various categories of payers, including Medicare, Medicaid, and managed care organizations. Understand the impact of these payers on reimbursement policies for healthcare providers.
