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Questions and Answers

What legislative act allowed billing approval for nonphysician practitioners like NPs?

Social Security Act

Affordable Care Act of 2010

Balanced Budget Act of 1997 (correct)

Medicare Improvement for Patients and Providers Act

What percentage of the fee schedule rate is used for payments to NPs by CMS?

50%

85% (correct)

75%

100%

What is the primary requirement for Medicare providers when submitting claims?

They must accept the CMS-approved amount as full payment. (correct)

They must charge double the CMS-approved amount.

They can refuse any payment if not satisfactory.

They must submit only covered service claims.

Which type of healthcare service does Medicare Part A primarily cover?

Hospital inpatient services Signup and view all the answers

What is the copayment amount for beneficiaries in a skilled nursing facility after 20 days?

$185.50 per day Signup and view all the answers

Which of the following statements is true regarding lifetime reserved days under Medicare?

They can use up to 60 lifetime reserved days after 90 days of continuous hospitalization. Signup and view all the answers

How are Medicare premiums calculated?

Based on quarters of lifetime work where Medicare taxes were paid. Signup and view all the answers

What happens to all costs incurred beyond the lifetime reserve days?

All costs are paid by the patient. Signup and view all the answers

What are considered third-party payers for healthcare services?

Indemnity insurance companies Signup and view all the answers

Which part of Medicare covers hospital inpatient services?

Medicare Part A Signup and view all the answers

What is the reimbursement rate for nurse practitioners billing under CMS guidelines?

85% of the fee schedule rate Signup and view all the answers

What is the Medicare Part A hospital deductible for the year 2021?

$1,484 Signup and view all the answers

Which of the following does NOT fall under the category of third-party payers?

Private pay patients Signup and view all the answers

What is required for providers to bill Medicare for their services?

Obtaining a National Provider Identifier (NPI) Signup and view all the answers

How is the copayment structured for skilled nursing facility (SNF) postacute care from days 21 to 100?

$185.50 per day Signup and view all the answers

Which of the following is a characteristic of Managed Care Organizations (MCOs)?

They typically pay less than indemnity insurance Signup and view all the answers

What percentage of the physician's fee schedule do nurse practitioners receive as reimbursement from CMS?

85 Signup and view all the answers

What is the coinsurance amount for hospital stays beyond 90 days in a benefit period?

$742 per day Signup and view all the answers

Which piece of legislation allowed billing approval for nonphysician practitioners like nurse practitioners?

The Balanced Budget Act of 1997 Signup and view all the answers

Which of the following statements about private pay patients is true?

They pay for services directly without third-party involvement. Signup and view all the answers

Which of the following correctly describes the patient’s responsibility for coverage under Medicare B?

20 Signup and view all the answers

What was the annual deductible for Medicare B in the year 2021?

$203 Signup and view all the answers

Which days of a hospital stay incur no additional payment for beneficiaries under Medicare A?

1 Signup and view all the answers

What percentage of the physician fee schedule is reimbursed to CMS-covered physicians?

100 Signup and view all the answers

What percentage of the allowed rate does CMS pay for services covered by the physician fee schedule?

80% Signup and view all the answers

What is the Medicare B deductible for the year 2021?

$203 Signup and view all the answers

Which of the following is true regarding the reimbursement rates for Nurse Practitioners (NPs)?

NPs are reimbursed at 85% of the physician's fee. Signup and view all the answers

What is the recommended practice regarding patient out-of-pocket payments before providing services?

It is best practice to collect payments before rendering services. Signup and view all the answers

What is one reason for collecting copayment and deductible payments before services are rendered?

It simplifies patient billing later. Signup and view all the answers

What is the typical monthly premium cost for a secondary insurance plan for Medicare beneficiaries?

$50 to $300 Signup and view all the answers

Which of the following is NOT a component of patient out-of-pocket expenses under Medicare?

Monthly premium of Medicare Part A Signup and view all the answers

What administrative strategy did the physician fee schedule aim to achieve?

Promote better accessibility and quality. Signup and view all the answers

What is the primary focus of Title I of HIPAA?

Protecting health insurance coverage for workers and their families Signup and view all the answers

Which of the following interventions is classified as primary prevention?

Weight control programs Signup and view all the answers

What does Title II of HIPAA primarily address?

Electronic data interchange in health care Signup and view all the answers

Which of the following is a component of tertiary prevention?

Management of chronic diseases like respiratory issues Signup and view all the answers

How does HIPAA legislation contribute to the management of healthcare practices?

By setting security standards for patient information Signup and view all the answers

Which example represents secondary prevention?

Monitoring blood pressure levels Signup and view all the answers

What is one key aspect of primary prevention strategies?

Educating about smoking cessation Signup and view all the answers

What financial impact is associated with states that accept Medicaid expansion?

Increased federal investment Signup and view all the answers

What percentage of the discounted rate do beneficiaries pay for brand drugs during the coverage gap phase?

25% Signup and view all the answers

Which phase does not require beneficiaries to pay any costs before meeting the deductible?

Catastrophic phase Signup and view all the answers

What is a potential disadvantage of Medicare Advantage (MA) plans for beneficiaries?

Limited choice of healthcare providers Signup and view all the answers

How do Medicare Advantage carriers receive payment for the services they provide?

Subsidies per member from CMS Signup and view all the answers

What major policy change was included in the ACA regarding the donut hole?

Gradual closure of the donut hole by 2020 Signup and view all the answers

Which of the following statements is true about the financial viability of Medicare Advantage plans?

They have been less financially viable due to high healthcare costs. Signup and view all the answers

What is one reason many Medicare Advantage carriers might exit the market?

Higher costs incurred beyond CMS payments Signup and view all the answers

What is the role of the initial coverage phase in the Medicare drug coverage structure?

Beneficiaries pay a percentage of the drug cost with some assistance. Signup and view all the answers

What must a healthcare provider obtain in order to bill Medicare services?

A National Provider Identifier (NPI) Signup and view all the answers

Which statement accurately describes the payment structure for hospital stays under Medicare A?

No additional payment is required for stays of 1 to 60 days. 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?

Health maintenance organization (HMO) plans Signup and view all the answers

What is the primary purpose of the federal funding in the Medicaid program?

To assist states in offering medical care to eligible low-income individuals Signup and view all the answers

What is the maximum coinsurance amount for a Medicare patient who has used their lifetime reserve days?

All costs incurred must be paid by the patient Signup and view all the answers

Which income eligibility method was established by the ACA for Medicaid?

Modified Adjusted Gross Income (MAGI) Signup and view all the answers

What regulatory body is responsible for the authority over Advanced Practice Registered Nurses (APRNs)?

The individual state nurse licensing boards Signup and view all the answers

How are payments structured for nurse practitioners under CMS billing rules during 2021?

85% of the fee schedule rate Signup and view all the answers

Which groups are specifically exempt from meeting the MAGI requirements for Medicaid eligibility?

Individuals over 65 years and those with disabilities Signup and view all the answers

What is a primary requirement for a healthcare provider in order to accept Medicare assignments?

They agree to accept the CMS-approved amount as full payment. Signup and view all the answers

What is a significant condition that must be met for Medicaid payments to providers?

Providers must accept Medicaid's lower payment as payment in full Signup and view all the answers

What type of hospital payment applies to facilities that care for a disproportionate share of Medicaid-eligible patients?

Disproportionate-share hospital payments Signup and view all the answers

What happens if a Medicare beneficiary exceeds the lifetime reserved days for hospital stays?

They are completely responsible for all remaining costs. Signup and view all the answers

What is the out-of-pocket expense for a beneficiary in a skilled nursing facility after 100 days?

$742 coinsurance per day used beyond the benefit period. Signup and view all the answers

How does the federal government support state spending on qualifying Medicaid services?

By matching dollar spending for qualifying mandatory services Signup and view all the answers

What change has occurred in the enrollment process for Medicaid and CHIP in recent years?

A reduced delay experienced during enrollment and renewal Signup and view all the answers

What is the primary impact of the U.S. Supreme Court ruling on ACA Medicaid expansion?

States could choose not to participate in Medicaid expansion. Signup and view all the answers

Which of the following categories is NOT included in the general categories of third-party payers?

Charitable organizations Signup and view all the answers

How does Medicaid expansion generally affect the quality of care in participating states?

It improves quality of care due to increased funding. Signup and view all the answers

What role do the Centers for Medicare and Medicaid Services (CMS) guidelines play for third-party payers?

They serve as a foundation for all payer source policies. Signup and view all the answers

Which of the following best explains the consequences of states not accepting Medicaid expansion funds?

Lower quality of care and reduced access for Medicaid patients. Signup and view all the answers

What economic impact is generally observed in states that accept Medicaid expansion?

Positive budget and economic outcomes from federal investment. Signup and view all the answers

What is the primary reason for the political opposition to Medicaid expansion under the ACA?

Concerns regarding federal overreach into state healthcare. Signup and view all the answers

In what context do APRNs demonstrate cost savings compared to traditional providers?

APRNs are reimbursed at a lower rate than 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?

$8,850 Signup and view all the answers

Which of the following Medicare parts does NOT require a monthly premium in some plans?

Medicare C Signup and view all the answers

What is the deductible amount for Medicare Part B in 2024?

$240 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.

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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.