Medicare ch. 12 key terms

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45 terms

Advance Beneficiary Notice

ABN, An agreement given to the patient to read and sign before rendering a service if the participating physician thinks that it may be denied for payment because of medical necessity or limitation of liability by Medicare. The patient agrees to pay for the service: also known as the waiver of liability agreement or responsibility statement.

approved charge

A fee that Medicare decides the medical service is worth, which may or may not be the same as the actual amount billed. The patient may or may not be responsible for the difference.

assignment

A transfer, after an event insured against, or an individual's legal right to collect an amount payable under an insurance contract. For Medicare, an agreement in which a patient assigns to the physician the right to receive payment from the Medicare administrative contractor. Under this agreement, the physician must agree to accept 80% of the allowed amount as payment in full once the deductible has been met. For TRICARE, providers who accept assignment agree to accept 75% or 80% of the TRICARE allowable charge as the full fee, collecting the deductible and 20% or 25% of the allowable charge from the patient.. With other carriers, accepting assignment means that, in return for payment of the claim, the provider accepts the terms of the contract between the patient and carrier. The provider also accept the payment from the carrier as payment in full with no balance billing to the patient.

benefit period

A period of time for which payments for medicare inpatient hospital benefits are available. a benefit period begins the first day an enrollee is given inpatient hospital care by qualified provider and ends when the enrollee has not been inpatient for 60 consecutive days. for disability insurance, it is the maximum amoun of time that the benefits will be paid to the injured or ill person for disability

Center for Medicare and Medicaid Services

CMS, Formerly known as the Health Care Financing Administration (HCFA), CMS divides responsibilities among three divisions: The Center for Medicare Management, the Center for Beneficiary Choices, and the Center for Medicaid and State Operations

Correct Coding Initiative

CCI, Federal legislation that attempts to eliminate unbundling or other inappropriate reporting of procedural codes for professional medical services rendered to patients

crossover claim

A bill for services rendered to a patient receiving benefits simultaneously from medicare and Medicaid or from Medicare and a Medigap plan. Medicare pays first and then determines the amounts of unmet Medicare deductible and coinsurance to be paid by the secondary insurance carrier. The claim is automatically transferred (electronically) to the secondary insurance carrier for additional payment.

diagnostic cost groups

DCGs, A system of Medicare reimbursement for HMOs with risk contracts in which enrollees are classified into various DCGs on the basis of each beneficiary's prior 12-month hospitalization history.

disabled

For purposed of enrollment under Medicare, individuals younger than 65 years of age who have been enttitled to disability benefits under the Social Security Act or the Railroad Retirement system for at least 24 months are considered disabled and are entitled to Medicare.

end-stage renal disease

ESRD, Individuals who have chronic kidney disease requiring dialysis or kidney transplant are considered to have ESRD. To qualify for Medicare coverage, an individual must be fully or currently insured under Social Security or the Railroad Retirement system or be the dependent of an insured per. Eligibility for Medicare coverage begins with the third month after beginning a course of renal dialysis. Coverage may commence sooner if the patient participates in a self-care dialysis training program or receives a kidney transplant without dialysis.

fiscal intermediary

An organization under contracts with the government that handles claims under Medicare Part A from hospitals, medical facilities, home health agencies, or providers of medical services or supplies.

formulary

A list of drugs that a health insurance plan covers as a benefit

hospice

A public agency or private organization primarily engaged in providig pain relief, symptom management, and supportive serviced to terminally ill patients and their families in their own homes or in a homelike center.

hospital insurance

Known as Medicare Part A. A program providing basic protection against the cost of hospital and related after-hospital services for hospital services for individuals eligible under the Medicare program

intermediate care facilities

ICFs, Institutions furnishing health- related care and services to individuals who do not require the degree of care provided by acute care hospitals or nursing facilities.

limiting charge

A percentage limit on fees, specified by legislation, that nonparticipating physicians may bill Medicare beneficiaries above the fee schedule amount.

medical necessity

The performance of services and procedures that are consistent with the diagnosis in accordance with standards of good medical practice, performed at the proper level, and provided in the most appropriate setting. Medical necessity must be established before the carrier may make payment.

Medicare

a nationwide health insurance program for persons 65 years of age and older and certain disabled or blind persons regardless of income, administered by HCFA

Medicare administrative contractor

Insurance carrier that receives and processes claims from physicians and other suppliers of service for Medicare Part B; formerly referred to as fiscal intermediary, Medicare carrier, fiscal agent, Medicare Part B carrier, or contractor.

Medicare Part A

Hospital benefits of a nationwide health insurance program for persons 65 years of age and older and certain disabled or blind persons regardless of income, administered by CMS. Local Social Security offices take application an supply information about the program.

Medicare Part B

Medical Insurance of a nationwide health insurance program for persons 65 years of age and older and certain disabled or blind persons regardless of income, administered by CMS. Local Social Security offices take application an supply information about the program.

Medicare Part C

Medicare Plus Choice plan offer a number of health care options in addition to those available under Medicare Part A and Part B. Plans may include health maintenance organizations, religious fraternal benefit societies, and Medicare medical savings accounts

Medicare Part D

Stand-alone prescription drug plan, presented by insurance and other private companies that offer drug coverage that meets the standards established by Medicare. Other names for these plans are Part D private prescription drug plans (PDPs), or Medicare Advantage prescription drug plans (MA-PDs)

Medicare/Medicaid

Refers to an individual who receives medial or disability benefits from both medicare and Medicaid programs, sometimes referred to as a Medi-Medi case or a crossover

Medicare Secondary Payer

MSP, The primary insurance plan of a Medicare beneficiary that must pay for any medical care or services first before, Medicare is sent a claim

Medicare summary notice

A document received by the patient explaining amount charged, Medicare approved, deductible, and coinsurance for medical services.

Medigap

MG, A specialized supplemental insurance policy devised for the Medicare beneficiary that covers the deductible and copayment amounts typically not covered under the main Medicare policy written by a nongovernmental third-party payer. Also known as Medifill

national alphanumeric code

Alphanumeric codes developed by HCFA.

nonparticipating physician

nonpar, A provider wjp decides not to accept the determined allowable charge from an insurance plan as the full fee for care. Payment goes directly to the patient in this case, and the patient in this case, and the patient is usually responsible to pay the bill in full.

nursing facility

NF, A specially qualified facility that has the staff and equipment to provide skilled nursing care and related services that are mecially necessary to a patient's recovery; formerly know as a skilled nursing facility.

participating physician

A physician who contracts with an HMO or other insurance company to provide services; A physician who agrees to accept payment from Medicare (80% of the approved charges) plus payment from the patient (20% of the approved charges) after the $100 deductible has been met.

Physician Quality Reporting Initiative

PQR, Voluntary pay-for-reporting program for providers who successfully report quality information related to services provided to patients under Medicare Part B between July 1 and December 31, 2007

premium

The cost of insurance coverage paid annually, semiannually, or monthly to keep the policy in force. In the Medicare program, monthly fee that enrollees pay for Meicare Part B medical insuance. This fee ins updated annually to reflect changed in program costs.

prospective payment system

PPS, A method of payment for Medicare hospital insurance based on diagnosis-related groups

Quality Improvement Organization

QIO, A program that replaced the peer review organization (PRO) programs and is designed to monitor and improve the usage and quality of care for Medicare beneficiaries

qui tam action

an action to recover a penalty, brought by an informer in a situation in which one portion of the recovery goes to the informer and the other portion to the state or government

reasonable fee

A charge is considered reasonable if it is deemed acceptable after peer review even though it does not meet the customary or prevailig criteria. This includes unusual circumstances or complications requiring additional time, skill,ore experience in connection with a particular service or procedure. In Medicare, the amount on which payment is based for participating physicians

relative value unit

RVU, A monetary value assigned to each service based on the amount of physician work, practice expenses, and the cost of professional liability insurance. These three RVUs are then adjusted according to geographic area and used in a formula to determine Medicare fees.

remittance advice

A document detailing services billed and describing payment determination issued to providers of Medicare or Medicaid programs: also known in some programs as an explanation of benefits.

resource based relative value scale

RBRVS, A system that ranks physician services by units and provides a formula to determine a Medicare fee schedule.

respite care

A short term hospice inpatient stay for a terminally ill patient to give temporaty relief to the person who regularly assists with home care of a patient

Supplemental Security Income

SSI, A program of income support for low-income aged, blind, and disabled persons established by Title XVI of the Social Security Act.

supplementary medical insurance

SMI, Part B -- medical benefits of Medicare program

volume performance standard

VPS, The desired growth rate for spending on Medicare part B physician services, set each year by Congress

whistle blowers

Informants who report physicians suspected of defrauding the federal government.

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