Master Study Guide II

Master Study Guide II

1.  Medicare is for people at or over the age of ______, those of any age with ______, and certain disabled people under the age of _____.

2.  Medicare cards identify if the patient has Parts A and B and will list the date these benefits became ______.

3.  Medicare claim numbers are usually the patient or spouse’s ______with a ______/______prefix.

4.  Common Codes:

a.  Primary Wage Earner ______

b.  Retired Railroad Employee ______

c.  Entitled through spouse ______

d.  Child ______

e.  Widow ______

f.  Widower ______

g.  Disabled Widow ______

h.  Disabled Widower ______

5.  Medicare beneficiaries are automatically eligible on their ______birthday but must apply ______months beforehand.

6.  Inpatient hospital services are covered under Part ______; Outpatient services Part ______.

7.  Beneficiaries can pay private insurance companies to offer HMO or PPO coverage instead of traditional Medicare coverage through Part ______.

8.  This is also known as ______.

9.  Part ______helps cover prescription drug plans.

10.  Part A helps pay for inpatient ______care, ______, home health agencies and ______.

11.  Inpatient Hospital Care is for up to ______days each benefit period.

12.  The ______day or ______hour rule allows all pre-admission or diagnostic services provided within this time prior to admission to be included with the inpatient payment. Doesn’t cover ______services.

13.  Medicare’s BENEFIT PERIOD for inpatient hospital and skilled nursing home facility care is ______days. The BENEFIT PERIOD begins on the ______day of services and ends ______days following discharge if those days aren’t interrupted by skilled care in another facility.

14.  Medicare beneficiaries can have an ______number of BENEFIT PERIODS but they must pay the inpatient ______for each period.

15.  LIFETIME RESERVE DAYS refer to ______additional days of hospitalization when beneficiary is an inpatient for a period greater than ______days. These days can be used only ______in a lifetime.

16.  Important Message from Medicare (IMM) is given to all inpatient ______recipients and explains their rights to care and follow up care after discharge. It also gives them a number to call if they feel they are being discharged too ______. Hospitals cannot force beneficiaries to leave while their case is being ______.

17.  Skilled Nursing Facility Care – if medically ______, Part A pays for up to 100 days for each benefit period. Medicare pays all of first ______days, and patients pay a co-insurance for days______- ______.

18.  Home Health Care – Medicare covers full ______cost of covered HHC services. Patients pay only 20% co-insurance on equipment such as walkers/wheelchairs.

19.  Medicare (Part B) Insurance – helps pay for ______services, ______hospital services (including ER visits), ambulance transportation, diagnostic tests, lab, some preventative care, etc. It pays ______% of approved charges for most covered services. Beneficiaries are responsible for paying ______deductible per calendar year and the remaining ______% approved charges.

20.  Medicare (Part C) Insurance – Medicare beneficiaries can elect to assign their benefits to a ______insurance company that has special coverage for seniors…usually an HMO/PPO.

21.  Medicare (Part D) Insurance – helps cover ______drugs and may lower prescription costs.

22.  Be sure to mention to all Medicare recipients that their yearly Medicare Enrollment Review is ______through ______. They can make changes during this time.

23.  Except for certain limited cases in ______and ______, Medicare does not pay for treatment outside the U.S.

24.  Medicare Part A does not pay for convenience items such as ______and ______, private rooms (unless ______), or private duty nurses. Skilled nursing facilities are for ______purposes only. Medicare does not pay for ______services (bathing, eating, or getting dressed).

25.  Medicare Part B usually doesn’t pay for ______, physical examinations or services not related to treatment of an ______or ______. It doesn’t pay for dental care, cosmetic surgery, foot care, hearing aids, eye exams, or eyeglasses.

26.  The ADVANCED BENEFICIARY NOTICE should be given to Medicare recipients if Medicare may not consider the service ______and there is a good chance the patient will have to pay. If the ABN isn’t ______before service is rendered and Medicare doesn’t pay, the patient ______be held responsible for the service. If the ABN was signed, then the patient may be billed.

27.  Many Fiscal Intermediaries are using ______that compares the diagnosis code with a list of medically necessary services. Therefore it is extremely important that the correct code is assigned to the diagnosis.

28.  Medicare is the secondary payer when another insurance is ______and therefore Medicare is the ______payer.

29.  A MEDICARE SECONDARY PAYER ______must be completed on all ______patients each time service is provided because this information can ______from visit to visit. Failure to do so can result in ______.

30.  Medicare is the SECONDARY PAYER if:

a.  Patient is 65 years old or older and is covered by a Group Health Insurance provided by an employer with ______or more employees for whom they or their ______works.

b.  Patient is under the age of 65 and ______, and they or a family member currently works at an employer with ______or more employees who covers them under Group Health Insurance.

c.  Patient has Medicare due to permanent kidney failure, known as ______.

d.  Patient has Medicare, but is suffering from an illness or injury covered under ______compensation, the federal ______lung program, no fault insurance, or any ______insurance.

31.  If patient retired before their Medicare entitlement date, but can’t remember their exact retirement date, then their entitlement date can also serve as their ______date.

32.  If a Medicare beneficiary worked beyond their entitlement date but cannot remember their exact date of retirement, and it has been at least ______years since they retired, you can subtract ______years from date of service as the retirement date.

33.  CMS regulations state that for recurring visits, where one account is created and the patient has several visits related to the same service (such as physical therapy), all charges for each visit are entered into ______account. But, you must verify the patient’s MSP information every ______days.

34.  Medicare avoids excessive INPATIENT stays by paying only a fixed amount according to the patient’s diagnosis. It will pay the ______rate regardless of actual hospital charges or length of stay.

35.  The only conditions where Medicare will pay more are if the hospital serves a great percentage of ______income patients or is an approved ______hospital. This extra amount is known as an ______.

36.  This DRG payment is important to keep in mind when a patient questions the total amount of their inpatient bill because Medicare’s reimbursement is rarely influence by the ______.

37.  Medicare reimbursement amounts for professional and most OUTPATIENT services are based on ______, which are tied to Current Procedural Terminology (CPT) codes and are based on national average costs.

38.  The amount the patient is responsible for when APCs are the method of payment will vary until the amount can be set at a standard ______% of the APC payment. This change will gradually be phased in to prevent the patient from being hit with a large _____ pay.

39.  For lab and physical therapy, Medicare pays according to a ______schedule.

40.  Unintentional failure to follow CMS guidelines carries severe ______and ______. In cases of intentional fraud, Medicare will not only pursue the hospital, but the ______as well.

41.  The three types of Medicare SUPPLEMENTAL Insurance coverage includes: ______(employer or union), ______(from a former employer or union), or ______(from a private company or group).

42.  MEDIGAP is private insurance designed to help pay Medicare ______sharing amounts such as co______, ______, and uncovered services.

43.  MEDICARE SELECT is a type of supplemental insurance that generally has lower premiums than other policies because each insurer has specific ______and often specific ______that participants must use, except in an ______, in order to receive full benefits. It is similar to an ______.

44.  MEDICARE BENEFICIARY NOTICES (MBN)- an easy to read monthly ______that clearly lists claims information.

45.  MEDICARE+CHOICE-plan that manages the Medicare coverage for its members and may provide benefits like coordination of care or reduce out of______expenses. Members may also get prescription drug benefits or additional days in the hospital. Medicare pays a set amount of ______for your care every month to these private health plans. Patient must have Part ______and ______to be eligible.

46.  MEDICARE MANAGED CARE PLAN PROCESS – in most cases, patients can only go to certain ______that agree to treat members of the plan

a.  Doctors can join or leave Managed Care Plans ______.

b.  Patients usually need a ______from a Primary Care Physician to see a specialist and risk higher co-pays without one.

c.  Patients pay ______if they go outside the network, unless it’s an emergency or urgent care.

d.  Some Managed Care Plans offer a Point of Service option which allows patients the option to go to doctors ______the network, but pay more.

47.  PRIVATE FEE FOR SERVICE- in this case the private company rather than ______determines how much it pays and how much the patient pays for services.

a.  Patients can go to any ______that accepts the terms of plan’s payment

b.  Private company pays a ______for each service, and patient may also have a ______.

c.  Patients could pay ______if the plan lets provider bill more than the plan pays for services.

48.  In order to receive Medicare through other health plan choices, the beneficiary must have part ______and part _____, continue to pay the monthly part B ______, live in the plan’s service ______, and not have ______.

49.  Medicare beneficiaries in managed care plans should have a Medicare card as well as a ______card. They still receive Medicare ______services and retain all Medicare ______and protections.

50.  If a patient has Medicare HMO and is in an automobile accident, who should be the primary payer?

51.  MEDICAID was established in 1965 to provide health care coverage for certain low income people. Each state can determine ______standards, which benefits and ______to cover, and to set payment rates.

52.  MEDICAID QUALIFICATIONS are certain low income families with ______, aged, blind, or disabled people on Supplemental Security Income, certain low income ______women and children, and certain people who qualify due to ______medical expenses.

53.  MEDICAID COVERED SERVICES must include ______and outpatient hospital services, lab and x-rays, skilled nursing and home health services, family planning and periodic health check-ups, diagnosis, and treatment for ______.

54.  TRADITIONAL MEDICAID eligibility is evaluated on a ______basis. The Medicaid card is issued to the ______of each family, which will list the names and ______ID numbers for each person covered.

55.  HMO MEDICAID contracts are determined by the State and contracts are usually arranged so that claims are submitted to and paid by the HMO, which is reimbursed by Medicaid.

56.  Medicaid is a ______payer with respect to Medicare.

57.  WORKER’S COMPENSATION – services related to the result of ______related accidents or injuries and are paid by the employer or the employer’s workers compensation insurance company.

a.  The ______must authorize worker compensation services. Employer must be contacted for ______. For billing, a claim number and the name of ______authorizing the service is required.

b.  Key information to obtain in Worker’s Comp cases: ______and date of injury, type of ______, name of ______and ______person, their ______supervisor, Employee insurance information (in case injury is determined ______to be work related), and enter patient classification as “Worker’s Compensation” and whom the bill should be sent to.

58.  AUTO INSURANCE – usually primary for ______victims of auto accidents.

a.  If patient has no health insurance, then auto insurance would be ______.

b.  If patient has Medicare or Medicaid, then auto insurance is ______.

c.  Whenever possible, obtain the claim ______, ______address, and ______name and phone number.

59.  LIABILITY – coverage for injuries resulting from ______of another party. For example, if the patient slipped and fell on a freshly mopped floor in a business and a sign was not posted that the floor was wet, the business would be liable. Healthcare facilities have their own policies regarding billing liability cases. There is no insurance ______for liability coverage.

60.  COMMERCIAL INSURANCE – Insurance that is ______Medicare, Medicaid, Federal, State or County Programs. Blue Cross, Auto, PPO, HMO are considered ______insurance. Typically commercial beneficiaries are not required to select a ______or go to a specific ______.

61.  PREFERRED PROVIDER ORGANIZATIONS (PPOS) – PPOS are contracts between employers, ______, and ______.

a.  Doctors and hospitals provide services at a ______in return for receiving large volumes of ______who are PPO members.

b.  These doctors/hospitals are known as participating ______.

c.  Members do not have to select a PCP but must use a participating provider to obtain ______coverage.

d.  Choosing to go to a non-participating provider results in a coverage ______and the member has to pay more out of ______.

e.  Not all PPOs have PPO written on the ______. Healthcare facilities usually have a ______of PPOs that the facility has contracts with available to the staff. PPO cards usually have the co-pay amounts for ER/UC office visits.

62.  HEALTH MAINTENANCE ORGANIZATION (HMO) – insurance plans that strive to ______health care costs by requiring members to receive services at designated ______.

a.  Therefore, all services except those in ______situations must be provided or ______by a participating physician.

b.  Members typically select a ______who is responsible for overseeing their healthcare and approves non-emergency services.

c.  Not all cards have ______on them. Most HMOs issue cards to each family member with their name instead of the policyholder’s. Many add a suffix to the end of the policy holder to identify the cardholder’s relationship to the subscriber. For example, the policy holder’s suffix could end in 00 or 01, with the spouse’s being 01 or 02, and other dependents being 02, 03, etc.

d.  So if I am the policy holder, my suffix would be 00, my wife’s would be ______, my oldest child would then be ______, and my youngest child would be ______.

e.  Many HMO cards display the ______’s name and phone number as well as co-pay information. Some HMOs specify that non-participating claims be sent to a different ______than participating claims.