Please post initial responses and peer responses to the following discussion questions listed below:
- What are Medicare Parts A and B, and how do they affect coding? What are common types of Medicare fraud?
The physician fee schedule is updated April 15 of each year. What three basic elements compose this fee schedule? What are the advantages of being paid in this manner?
Debra Rabbani posted Aug 21, 2023 11:48 PM
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Question 1:
What are Medicare parts A&B, and how
do they affect coding?
Medicare part A covers inpatient hospital
stays.
Medicare part B covers certain doctors’
services, outpatient care, medical supplies,
and preventive services. Original Medicare
coverage consists of Part A and Part B, but
there are also two other parts which are
Medicare C and D.
Part A claims are for care provided in an inpatient
facility, such as a hospital, the provider is paid
directly by Medicare. Once Medicare has
reimbursed the facility for the appropriate
services, any remaining balance, including
deductibles, copayments, coinsurance payments,
or other fees, must be taken care of by the facility
by billing the patient directly.
These claims are filed using the UB-04 or CMS1450 forms. This form is a uniform hardcopy
claim form that is used for third-party providers.
This is the only form that is accepted by Medicare
from hospitals and skilled nursing facilities.
Part B services cover certain physician s’
services, outpatient care, medical supplies,
and preventive services. R eimbursement
depends on whether or not the provider accepts
Medicare assignment. For providers that accept
assignment for the specific claim, Medicare will
reimburse them for 80 percent of the Medicare
approved amount. Then, the provider will bill the
patient for the remaining 20 percent of the
procedure cost.
Part B claims are filed using the CMS-1500
form. This is the standardized claim for that is
used by healthcare providers that contract with
Medicare.
For providers that do not accept assignment for
the specific procedure, Medicare will pay the
patient directly for the reimbursement amount.
Then, the patient will be responsible for providing
the full payment to the provider.
What are common types of Medicare
fraud?
There are numerous types of fraud associated
with Medicare. The most prevalent Medicare
fraud happens in many ways. It most
commonly occurs in: Billing for institutional
facilities such as nursing homes, residential
facilities, hospitals, home health, and
hospice. Billing for physician visits and
services not rendered or not medically
necessary. Medicaid fraud is very prevalent
in our society and is costing taxpayers
millions of dollars and institutions should be
audited to prevent fraud.
Question 2:
The physician fee schedule is updated April
15th of each year. What three basic
elements compose this fee schedule?
The Medicare Physician Payment
Schedule’s impact on a physician’s
Medicare payments is primarily a function
of 3 key factors:
The resource-based relative value scale
(RBRVS)
• The geographic practice cost indexes
(GPCI)
• The monetary conversion factor.
What are the advantages of being paid in this
manner? Fee schedules are a list of fees for
procedures that insurance companies use to
determine the reimbursement rates for
physicians. They help billing companies and
office staff determine how much money to
•
collect from their patients or clients to put
towards their deductibles and co-insurance.
The advantages of being paid in this manner
is to guide the physicians to provide clear and
reasonable charges for the patient’s that they
service. The key point is regarding reliability
and transparency because the physician
knows the reimbursement rate of the medical
procedure they perform, and they can plan
accordingly to manage their operations and
serve their patients.
Module 1- Question #1
Contains unread posts
Jessi Marin Guarin posted Aug 24, 2023 11:29 PM
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1. What are Medicare Parts A and B, and how do they
affect coding? What are common types of Medicare
fraud?Medicare, a federal health insurance program
in the United States, provides coverage to qualified
people 65 and older and some disabled people. The
program is divided into several parts, with Parts A
and B serving as its focal points. Hospice care,
inpatient hospital stays, skilled nursing facilities,
and some home health services are all covered by
Medicare Part A, which is paid for by payroll taxes.
To accurately reflect patient treatment during stays,
proper coding requires the assignment of precise
diagnostic (ICD-10) and procedure (CPT/HCPCS)
codes. Medicare Part B, which has a monthly fee,
covers outpatient treatment, doctor visits,
preventative services, and some types of home
health care. Here, coders assign codes to services
provided outside of hospitals, affecting how much is
reimbursed. Medicare fraud involves upcoding,
unbundling, charging for services that haven’t been
provided, kickbacks for prescriptions or referrals,
and identity theft. It also includes dishonest actions
taken to obtain improper payments. These actions
jeopardize the program’s and the funding sources’
integrity.
Module 1 Discussion Topic 1
Contains unread posts
Alli Kallenbach posted Aug 22, 2023 9:49 PM
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What are Medicare Parts A and B, and how do they affect
coding? What are common types of Medicare fraud?
The Medicare Program was established in 1965 with the
passage of the Social Security Act. The program has
increased the involvement of the government in health
care. Medicare Part A is hospital insurance, and Medicare
Part B is supplemental medical insurance. Medicare Part
A pays for the cost of care while Part B pays for physician
services and medical equipment that is not paid for
under Part A. Furthermore, Part A insurance can help
cover hospice and other home cares.
Hospitals report Part A Medicare services by using
diagnosis and procedure codes. They specify Medical
Severity-Diagnosis Related Groups (MS-DRG)
assignment. Part B Medicare services are reported by
using ICD-10 CM diagnosis codes as well as the CPT
codes, which are for the physician or other health
services. It is also reported using HCPCS codes for
additional supplies and services such as medical supplies
and orthotics.
Medicare is subject to fraud, as of a claim is filed for a
service that was carried out when that service was not
provided. Most patients sign a standing approval that
designates benefits to the provider, and it is also kept on
file for the medical staff. The standing approval is very
convenient for both the patient and the coding staff.
After receiving a service, the Medicare claim is filed for
the patient automatically; however, standing approval
also makes it easy for someone to submit charges for
services that were never provided. Common types of
Medicare fraud include billing for services not furnished,
misrepresenting a diagnosis to justify a payment,
soliciting, offering, or receiving a kickback, and
unbundling or “exploding” charges.
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