Question

iew the following lecture: Medicare and Medicaid Introduction: Medicare and Medicaid are federal programs that cover...

iew the following lecture:

  • Medicare and Medicaid

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:

  • Describe each program, Medicare and Medicaid.
  • Provide the major features of each program.
  • Discuss how these programs differ from each other.
  • Briefly describe the process of how to bill for each program.
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Answer #1

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:

  • Inpatient/outpatient hospital services
  • Family planning care
  • Pediatric services
  • Prescription drug costs
  • Dental healthcare and services
  • Mental health services
  • Occupational, physical, and speech therapy

Difference between Medicare and Medicaid:

  • They are two separate program run by the government.
  • Both are operated and funded by differentiation parts of the government.
  • They primarily serve different group of population.
  • Medicare is a federal program and Medicaid is federal and state program.
  • Medicare provides coverage for a person aged above 65 year or below 65 years with disability and does not consider the income. Medicaid provides coverage for a person whose income is very low.

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:

  • International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Codes: ICD-9-CM is the system by which official codes are assigned to medical diagnoses and procedures relating to hospital use in the U.S. The ICD-9-CM lists the official disease codes for relevant medical conditions and procedures. ICD-9-CM codes are a series of alphanumeric digits followed by a decimal point followed by one or two numeric digits.
  • Place of Service Codes: Place of service codes specify where the patient received their medical care or supplies. Place of service codes are ascribed to medical facilities such as inpatient hospitals, nursing facilities, and hospices. Place of service codes are typically two digits long.
  • Healthcare Common Procedure Coding System (HCPCS) Level II Codes: HCPCS Level II codes are used to identify and categorize supplies, services, and products not included in CPT codes. HCPCS Level II codes may include ambulance services and prosthetics. HCPCS Level II codes have a single letter followed by four numeric digits.
  • Current Procedural Terminology (CPT) Codes: CPT codes (also known as Level I HCPCS codes) are a subset of the HCPCS and they are used for identifying and categorizing medical procedures and services. CPT codes are created and revised as necessary by an official editorial board in conjunction with the American Medical Association. CPT does are five numeric digits long.
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