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“the contractor shall further insure that all medical, dental, and mental health services are secured from a Medicaid approved provider and that charges for services shall be at the Medicaid approved rates. If no Medicaid provider is available the contractor must make every

Most claims today are submitted through an electronic format directly or indirectly through a “clearinghouse” where claims are grouped and sent to the payer. Two primary payment grouping algorithms are DRG’s and APCs, both are used by Medicare for hospital payment and many commercial payers. Providers and payers use claims editing software to detect possible errors in claim submission to assure maximum payment for medical services and to shorten an amount of time from claim submission to payment. CMS has developed the National Correct Coding Initiative (NCCI) to promote national correcting coding methodologies and to control improper coding leading to inappropriate payment (Cleverley 26). CMS also has designated edit checks called the outpatient code edits (OCE). The OCE uses claim-level and line item-level information in the editing process. Each category in the OCE has six dispositions which help to ensure all Fiscal Intermediary/Medicare Administrative Contractor (FI/MACs). The four claim-level is rejection, denial, return to provider, and suspension; and the two-line item-level is rejection and

To conclude this report, there are four considerations of a legal and valid insurance contracts that patients may present at the provider’s office or clinic. The guide to understand and remember are as follows: (a) the patient or person insured must be a mentally competent adult and should not be under the influence of drugs or alcohol; (b) the insurance company must have a signed application and offer the policy to the patient, then the patient or person should accept the issuance of the policy without misrepresentation of facts on the application of the person being insured; (c) the services produced and sold or the exchange of value and the first premium payment should be submitted with the application considered must be presented together; and (d) there should be a legal purpose which is an insurable interest in the case of a person’s healthcare insurance policy. These are good guidelines to know and understand for the success of an administrative life cycle of a physician-based claim (CMS

The patient is informed about their coverage and the amount of copayment they would have to pay.

The topic of transitioning to the ICD-10 coding system has become a very big issue within the medical practice field. In fact, as of October 1, 2015, all physicians, hospitals, and medical providers are required by the federal government to be in full compliance using ICD-10 coding. ICD-10-CM codes allow for medical providers to provide as much information as possible about the patients state of health and all treatment provided as such. In addition, "The CPT coding system offers doctors across the country a uniform process for coding medical services that streamlines reporting and increases accuracy and efficiency (Ama-assnorg, 2015)."

Healthcare facilities are required to maintain licensure, certification, and accreditation in order to receive payments from federal government programs such as Medicare. Healthcare facilities must meet the minimum standards in order to operate, such as sufficient staffing, personnel employed to provide services, the quality of equipment, buildings, and supplies, and services provided, including health records. (LaTour, 2013) Medicare has developed Conditions of Participation and Conditions for Coverage, which identifies specific criteria that must be met in order to receive reimbursement from Medicare. Medicare implements these guidelines in order to

“I’m so sorry Mrs. Jones, but your insurance doesn’t cover that.” My mother stood, staring in disbelief at the $850 invoice that she received for her C-Pap machine. She had no clue how she was going to pay for it since her only income is her monthly social security disability disbursement, which is only $850. She desperately needed this machine for her Sleep Apnea but how would she afford this when she has so many other expenses? Why isn’t Medicare covering the cost of this machine? They covered the hospital stay that led to the diagnosis, so why not this? This scenario and similar ones present themselves far too frequently. As a solution, let’s discuss the basics.

The second obligation pertained to the circulation of the yearly prescription costs that followed the simple design for health costs which was normally the main part of the program’s expenses which were caused by a small number of the programs enrollees. The costs from the small amount of enrollees have the ability to be an enormous amount. Therefore, in order for the Medicare prescription program to offer most support for the participants that required it more than the catastrophic coverage had to have a lower co-pay amount attached to it. The model’s ending fee level has a five percent co-insurance obligation without a limit of on coverage. (Kaplan 2011)

The Medicare set-aside requirement is intended to prevent workers' compensation insurers from shifting the expense of the claimant's future medical treatment to Medicare. It is therefore only a hindrance to settlement when the settlement is intended to include compensation for future medical expenses. Some states have enacted workers' compensation laws that permit the settlement of only the indemnity portion of the claim, ending the insurer's liability for that portion while leaving the medical aspect of the claim open. In such instances, the insurer remains liable for the claimant's future medical treatment, and there is therefore no potential for shifting the cost to Medicare. As such, Medicare

* Medicare/Medicaid, to be sure the doctor is not banned from caring for Medicare/Medicaid patients

In the prior weeks, I had noted that many health care professionals utilize many different methods of practice, as well as implement a certain something to each of the medical cases that reflects that clinician’s style. No matter the endless routes to get to a diagnosis or the many diverse recommendations of treatment for that diagnosis, codes are the same. The medical field having a universal set of codes for diagnoses and procedures/interventions is very important because this set of codes keeps all clinicians, medical facilities and insurance companies on the same page. From what I read, the universal set of codes consists of two volumes

Realizing that Part A had some flaws, and could prove to become very expensive for those patients who were chronically ill and might not be able to afford treatment within the given coverage guidelines of Medicare Part A, CMS devised an optional Medicare Part B program, commonly referred to as “physician services”.  Medicare Part B not only adds additional insurance, but also covers other health care needs, particularly those not covered by Part A.  This Supplemental Medical Insurance (SMI) does not cover the services 100%, but rather 80%, where the beneficiary would only be responsible for the remaining 20%, also known as a coinsurance. (Lonchyna)

Computer-assisted coding is defined as the “use of computer software that automatically generates a set of medical codes for review, validation, and use based upon clinical documentation provided by healthcare practitioners”

ABN, notification is a notification to the patient in advance of services that Medicare probably will not pay for and the estimated cost to patient (formerly WOL, waiver of liability). Medicare has a form that can be downloaded and each commercial payer may have their own ABN form that needs to be requested by the providers.

Medically necessary treatments have to meet all of the points above to be covered by the plan.