iew the following lecture:
Introduction:
Medicare and Medicaid are federal programs that cover a large proportion of the US population with healthcare. The two have similar objectives in the area of providing care, but there are significant differences in them that concern reimbursement.
Tasks:
Medicare:
Medicare is a National Health Insurance Program in United States, begin in the year 1966 under the Social Security Administration (SAS) and now administered by the Centres for Medicare and Medicaid Services (CMS). Medicare provides health coverage to a person who is above 65 years or under 65 years and have a disability, no matter how much is their income.
Major features:
Medicare is divided into four parts.
Part-A: Provides coverage for hospital, skilled nursing and hospice services.
Part-B: Provides outpatient or medical coverage.
Part-C: Provides an alternative way to receive the Medicare benefits. It is also called Managed Medicare or Medicare Advantage which provides all part A and part B services covered by the original Medicare but they can do so with different rules, costs and restrictions that can affect how and when a person receives care. Medicare Advantage Plans typically have network restrictions in which a person will likely be more limited to their choice of doctors and hospitals. However Medicare Advantage Plan also provides additional benefits that original Medicare does not cover such as routine vision and dental care.
Part-D: Provides prescription drug coverage.
Medicaid:
Medicaid is a state and federal program which provides health coverage if a person have a very low income. It is a government insurance program for persons of all ages whose income and resources are insufficient to pay for health care.
Major features:
Medicaid offers benefits not normally covered by Medicare including personal care and nursing home care services. Medicaid recipients must be U.S. citizens or qualified non-citizens and may include lower income adults, their children and people with certain disabilities. Medicaid improves health insurance coverage, access to health care, financial security of the recipients and some health outcomes as well as economic benefits to states and health care providers.
Medicaid services covered:
Difference between Medicare and Medicaid:
Medical Billing for Medicare
Medicare functions as a single-payer healthcare system that pays insurance companies on behalf of people enrolled in its various programs. It’s up to medical billing officials to submit claims to appropriate MACs for processing after a person has received care covered by their Medicare plan.
Your duties as a medical billing specialist include inputting information from a provider’s superbill into compatible medical billing software. This includes provider information, patient information, information regarding treatment the patient received, and any relevant medical codes. Once you’ve input the necessary information into the medical billing software, you will either print out a CMS-1500 claim form for submission via mail or you will submit another claim form electronically to MAC for processing. As you file claims associated with Medicare, you will need to input medical codes similar to those you would use for Medicaid claim forms including CPT, ICD-9-CM, and place of service codes.
In order to properly understand how to file claims associated with Medicare coverage, consider the separate parts of the Medicare healthcare program.
Part A: medically necessary services
You will process claims associated with Part A of Medicare (medically necessary services) if you’re a medical billing specialist working with hospitals, clinics, and other facilities that offer inpatient care. You file Part A claims on behalf of your provider using the UB-04 medical claim form (also known as the CMS-1450 form). The UB-04 is the uniform institutional provider hardcopy claim form accepted for billing third-party providers. It is also the only hardcopy claim form that CMS accepts from institutional providers such as hospitals or skilled nursing facilities. When filing the UB-04 form, you should note that not all payers are required to complete the same data fields. Do your research to determine what fields are appropriate for each claim.
Part B: preventative care
As a medical billing specialist working for an outpatient healthcare provider, you will usually process claims associated with Part B of Medicare (preventative care). You file Part B claims using the CMS-1500 form, which is the standard claim form used by healthcare providers to billing Medicare carriers.
These forms must be purchased from legitimate sources other than the CMS, like the National Uniform Claim Committee (NUCC), which is responsible for updating and maintaining the CMS-1500. Be sure to check the guidelines for printing and preparing CMS-1500 forms before you process any claims. Note that the CMS-1500 form can also be used to bill some state Medicaid programs.
Parts C and D: to be filed separately
Claims related to Parts C and D of Medicare are relayed through a private insurer and should never be filed through Medicare. You won’t file Medicare claims with Parts C and D because private health plan carriers have agreements with Medicare to receive a certain amount per member every month. Part D of Medicare coverage may change depending on the person receiving care because coverage depends on the drugs involved. Some drugs aren’t covered by Part D at all. Thus claims filed through Parts C and D of Medicare should be treated like any other claim handled through a private health plan carrier.
Medical Billing for Medicaid
Medical billing for Medicaid is more complicated than medical billing for Medicare simply because Medicaid programs differ from state to state. Some citizens eligible for care in one state may not be eligible for care in another state, or they may receive a more or less benefits depending on the state in which they receive care. Billing codes, claim submission protocols, reimbursement rates, and other billing information will vary by state.
You will start the medical billing process for Medicaid by filling out a state claim form for the services and procedures covered. Most state Medicaid claim forms will be divided into main two parts: information regarding the patient and/or the insured person and information regarding the healthcare provider. As you complete the Medicaid form you will input codes from the following code sets:
iew the following lecture: Medicare and Medicaid Introduction: Medicare and Medicaid are federal programs that cover...
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