Question

Question from: Essentials of Health Care Finance By William Cleverley and James Cleverly

Describe/Explain the requirements for Medicare benefits and Medicare payments (pages 40-41)

1 Four Basic Medicare Benefit Programs - Part A - Part B - Part C - Part D

2 Medicare Payments - Hospital Inpatient * PPS and five exclusions * Medicare subpayment split * Modifiers (6) * Primary Diagnosis and Secondary Diagnosis - Physicians * Participating physician and Nonparticipatign physician - Hospital Outpatient * Ambulatory payment classifications * Balanced Budget Act - Skilled Nursing Facility * RUG IV Gropers (6 determinants) - Home Health Agencies * Home Health PPS (5 features)

Answer 1

ESSENTIALS OF HEALTH CARE FINANCE BY WILLIAM CLEVERELY AND JAMES CLEVERELY :

Requirements of medicare benefits can be availed by persons who are having 60 years and above, or the person or spouse who worked and not paid for medicare are eligible for this benefits. Persons who are residing in US for over 5 years are also eligible.

1. Four basic benefits of medicare program are as follows:

Part A - Inpatient or hospital coverage

Part B - Outpatient or medical coverage

Part C - Alternative medicare benefits

Part D - Coverages prescription drug

2. Medicare payments :

Hospital Inpatient -

* PPS (Prospective payment system) It is a method of reimbursement of medicare payments on fixed amounts.The payment derives for a particular service or in patient services and all have exclusions.

* Medicare sub payment split - It is a division of bills into one or more parts for in patient services.

* Modifiers - It is an adjustment made to payments on items and services of patients. It is applied to physicians by TIN (Tax Identification Number).

* Primary diagnosis and secondary diagnosis : Based on the level of disease condition and services rendering for diagnosis of patients medicare benefits and payments will alter.

Physicians -

* Participating physician and Non participating physician : Participating physicians accepts medicare benefits but don't accepts all the cases. They go on case on case basis and don't accepts full payments provided for health services. While participating physicians accepts medicare benefits as well as payments on cases.

Hospital outpatient -

* Ambulatory payment classifications : These are the systems which provide reimbursement for acute care facilities for out patient services. It is other wise called as APC.

*Balanced budget act : This act was established in the year of 1997. To cut off the high expenses the act reduced payments to health care providers and focused on welfare and children's health.

Skilled nursing facility -

* RUG Gropers : (Resource Utilization groups) .The Health and Human Service Office of the Inspector General identified high therapy Utilization Groups, where classification of system done to determine reimbursement levels for patients in skilled nursing facilities (SNF), which is important to monitor medicare services.

Home health agencies -

* Home health PPS : As per the balanced budget act 1997 payments are adjusted for the health care needs of beneficiary. It includes five features

1. Payment for 60 days

2. Adjusting payment for beneficiary needs

3. Paying more for the care of beneficiaries receiving costlier services

4. Adjustments to beneficiaries who visit only few visits during 60 days period

5. Adjustments for beneficiaries who are discharged and readmitted within a 60-day episode.