Medicare Re-Determination Process

Since the late 1980s, Medicare has reimbursed physician services using the Medicare Physician Fee Schedule (MPFS), which encompasses 10,000 procedure codes. Each code is assigned resource-based relative value units (RVUs), which are designed to reflect physician work, practice expense, and malpractice expense. To adjust for local differences in cost of living, each RVU is modified using geographic practice cost indexes (GPCIs) and then converted to dollars using a “conversion factor.” This system rewards physicians who produce a high volume of services; not surprisingly, Medicare Part B expenditures have grown rapidly.

This article discusses how Medicare Carriers and Fiscal Intermediaries use coverage determinations to establish medical necessity. When the condition(s) of a patient are expected to not meet medical necessity requirements for a test, procedure, or service, the provider has the obligation under the Beneficiary Notices Initiative to alert the Medicare beneficiary prior to rendering the service. The Medicare beneficiary is notified via the Advance Beneficiary Notice (ABN) (see page 235 in Appendix B).

Medicare enrollees in Utah have saved about $78 million on prescription drugs due to the ACA. Coverage for both brand name and generic drugs will continue to increase until the coverage gap is closed. The ACA also allows Medicare beneficiaries to seek preventive services without worrying about cost, due to the lack of deductibles and copays. This aids in detecting and treating health problems early on. In Utah in 2014, 220,972 individuals with Medicare used free preventive services. In addition to that, fraud is at a minimum due to tougher screening procedures, penalties, and technology developments.

The provider had an authorization on file approving the dental services advising that they were medically necessary. But when the provider billed, they only advised the services were dental and not medical. Therefore causing the claim to deny. Also, provider didn’t reference their authorization number in box 63 of their claim form which would have voided the claim from denying. This claim will be sent back to be reprocessed. Please advise and ETA of 01/13.

Medicare may not be perfect but until this program is changed it is what we have currently. Medicare has gone through changes since its inception in 1965. The most significant legislative change to Medicare--called the Medicare Modernization Act or MMA--was signed into law President George W. Bush, on December 8, 2003 (CMS, 2013). In a country with a complex healthcare system, a healthcare system that is a hot political stand for every presidential candidate and for each side to have valid arguments for and against is to be expected. But to say that Medicare is heading for disaster can be a stretch. Baby boomers who are entering Medicare eligibility age should not fret; there will be doctors there to service them and Medicare to pay those doctors.

Congress passed the Notice of Observation Treatment and Implication for Care Eligibility Act Notice Act in a unanimous vote on July 29, 2015. The President signed the bill on August 6, 2015.

Fifty years ago, Lyndon B. Johnson signed the Medicare program into law. “It has been a reliable guarantor of the health and welfare of older and disabled Americans by paying their medical bills, ensuring their access to needed health care services, and protecting them from potentially crushing health expenses.” (Hamel, Blumenthal, Davis, & Guterman, 2015, p. 479). With the encouragement of George W. Bush, congress passed the Medicare Modernization Act of 2003 (MMA). The MMA extended Medicare to include prescription-drug coverage, known as Medicare Part D. In 2013, Medicare covered the health care expenses for 52.3 million Americans, costing $583 billon. Originally, Medicare had difficulty controlling costs; physicians and hospitals were

enrolled in the new program. The $8 billion includes the state share of costs for both newly eligible adults and the additional Medicaid participation among currently eligible populations that would result from expansion. If all states implemented the Medicaid expansion, federal spending would increase by $800 billion, or 21 percent, compared to the ACA with no states implementing the expansion (Holahan, et al., 2013). Therefore, although the increase in spending per state is relatively small, the cost to our nation is exponential. With the national debt growing day by day, many believe that an exponential increase in national spending is a difficult thing to justify.

What do you think about this request? On my opinion we shouldn't place the claim on hold b/c we don't know for sure if Medicare will go back date it her coverage.If we place the claim on hold the patient don't go to receive the statement and we don't know if the patient will be continue to f/u her issue with her insurance. What do you think?

Medicare is our country’s health insurance program for people age 65 or older. Certain people younger than age 65 can qualify for Medicare, too, including those with disabilities and those who have permanent kidney failure. There are several changes for Medicare enrollees in 2017. The average increase is more than $4/month, and average premiums will be about $109/month for about 70 percent of enrollees. But the exact amount they’ll pay will vary depending on the dollar amount of the cost of living adjustment on their Social Security checks.

In the growing society, health care needs of people constitute an important area that requires a continuous surveillance. Especially, an accessibility to care appears to become a central issue for some population groups due to their poor socio-economic conditions and the family hardships. As a result, such groups are more vulnerable to a deficient health check up and end up with health issues. However, to overcome such health disparities, government agencies have come up with special policies. For instance, Medicare is one such policy. The preset description is concerned with highlighting about Medicare in view of its relevance to clinical practice.

The date of service should never be change. In order for the insurance to pay (if they accept to do it), billing should re-submit the claim with the information about that office visit. Medicare usually has a retroactive effective date for Part B premiums, which can be deducted from the lump sum of the SSDI. In some cases, then there may be Medicaid eligibility for a period of time and again, any services obtained during that time could be paid by Medicaid. If Nancy takes a chance and change the date and this action is made, it can lead to an investigation under Medicare Fraud. Medicare claims must be filed no later than 12 months after the date when the services were provided. If a claim isn't filed within this time limit, Medicare can't

According to the filing guidelines, providers must file claims for their Medicare patients within 12 months of the date of service.

The claim# 122535126600 was sent back on 02/11/2015 and overturned on 02/27/2015 referencing appeal# APP-910682. In the “01” claim notes, it gives reference to the same appeal and show that it was processed on 03/14/2015 and to see claim#122338990100. When you view claim# 122338990100, last time it was processed was on 11/08/2014. Could you please assist me with reprocessing this claim?

Please confirm. I don’t want to assume what the analyst mean by “Please provide exception memo to override denial.” Claim#132587959900 will apply additional money when refreshed. However, COB/OHI is preventing the money from paying out. But, Yolanda thinks that this note maybe the result of an untrained representative working Iowa appeals. An CLIA will look in the system like the screen shoot below. Could you please advise why the representative was not able to reprocess the appeal?