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    Billing Guidelines

    Uploaded by

    Syali Sasidharan
    NPPs such as PAs and NPs are reimbursed at a lower rate than physicians. There are two main types of insurance - commercial plans from private insurers like Blue Cross Blue Shield and government plans like Medicare and Medicaid. Medicare has several parts that cover different services - Part A covers inpatient hospital care, Part B covers outpatient care and physician services, Part C are Medicare Advantage plans managed by private insurers, and Part D covers prescription drugs. Medicaid is a state-run program that provides coverage for low-income individuals. Compliance rules and audits by organizations like OIG are needed to prevent healthcare fraud and abuse.

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    Billing Guidelines

    Uploaded by

    Syali Sasidharan
    30 views4 pages
    NPPs such as PAs and NPs are reimbursed at a lower rate than physicians. There are two main types of insurance - commercial plans from private insurers like Blue Cross Blue Shield and government plans like Medicare and Medicaid. Medicare has several parts that cover different services - Part A covers inpatient hospital care, Part B covers outpatient care and physician services, Part C are Medicare Advantage plans managed by private insurers, and Part D covers prescription drugs. Medicaid is a state-run program that provides coverage for low-income individuals. Compliance rules and audits by organizations like OIG are needed to prevent healthcare fraud and abuse.

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    NPPs such as PAs and NPs are reimbursed at a lower rate than physicians. There are two main types of insurance - commercial plans from private insurers like Blue Cross Blue Shield and government plans like Medicare and Medicaid. Medicare has several parts that cover different services - Part A covers inpatient hospital care, Part B covers outpatient care and physician services, Part C are Medicare Advantage plans managed by private insurers, and Part D covers prescription drugs. Medicaid is a state-run program that provides coverage for low-income individuals. Compliance rules and audits by organizations like OIG are needed to prevent healthcare fraud and abuse.

    Copyright:

    © All Rights Reserved
    Download as RTF, PDF, TXT or read online from Scribd
    Download as rtf, pdf, or txt
    30 views4 pages

    Billing Guidelines

    Uploaded by

    Syali Sasidharan
    NPPs such as PAs and NPs are reimbursed at a lower rate than physicians. There are two main types of insurance - commercial plans from private insurers like Blue Cross Blue Shield and government plans like Medicare and Medicaid. Medicare has several parts that cover different services - Part A covers inpatient hospital care, Part B covers outpatient care and physician services, Part C are Medicare Advantage plans managed by private insurers, and Part D covers prescription drugs. Medicaid is a state-run program that provides coverage for low-income individuals. Compliance rules and audits by organizations like OIG are needed to prevent healthcare fraud and abuse.

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    Hierarchy of providers

    NPPs - Non Physician Providers or MLP - Mid Level Providers or PE - Physician Extenders

    Eg - PA - Physiciann Assistants, Nursing Practitioners.

    NPPs are reimbursed lesser than the Physicians.

    Types of Insurance Companies

    Commercial and Government

    Private Insurance - Blue cross blue shield, Aetna

    Government Insurance - Medicare administered by CMS, Medicaid

    Patient age over 65

    Disablity

    Permanent Kidney failure or ESRD

    Medicare Part A -

    Covers IP hospital care, SNF, Hospice care and home healthcare

    Medicare Part B -

    Covers OP, Preventative care, Physician Services

    Its an optional benefit and patient has to pay premium every year which
    requires deductable and Co insurance

    Medicare Part C -

    Plan managed by private payers and approved by Medicare

    Plan may charge different copayments, coinsurance, deductable for


    services

    Combines the benefits of part A and part B sometimes Part D also

    Also called as Medicare Advantages

    Medicare Part D -

    Prescription drug program for all medicare beneficiaries

    Medicaid
    Health Insurance program for Low Income people especially for children and
    pregnant women

    Sponsored by state government

    State funded insurance programs providing coverage for children upto 21


    years includes Children medical services, Childrent Indigent disability
    services and children with special healthcare needs

    RBRVS - Resource Based Relative Value Scale

    Resource cost divided into 3 components

    Physician work (52%), Practice expense (44%) and professional liability insurance (4%)

    Medical Necessity

    Given services should be appropriate for the Diagnosis

    NCDs -National Coverage Determinations explains when Medicare will pay for the service
    or item.

    MAC - Medicare Administrative contractors is reponsible for interpreting national policies into
    regional policies called LCDs - Local Coverage Determinations

    ABN - The Advanced Beneficiary Notice explains patient liable to pay if Medicare denied the services
    and before proceeding to the procedure patient should be provided with the cost estimation for that
    particular procedure

    No ABN for non Medicare Patients

    HIPAA - Health Insurance Portability and Accountability Act

    Healthcare Providers

    Doctors, Dentists, Chiropractors, Psychologists, Clinics, Nursing homes & pharmacies

    Key provision of HIPAA is to share PHI to satisfy a particular purposes


    HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009

    HITECH allows patient to request audit trail on where their health information have been shared
    electronically

    FRAUD - (knowingly or willfully doing)purposefully bill for services that never given or bill for service
    that has higher reimbursement than the service provided

    ABUSE - payment for services billed by the provider in error that should not be paid by medicare

    Need for Compliance Rules and Audits


    The OIG Work Plan - sets forth a plan outlining its priorities for the fiscal year. Posts continuing work
    planning on its website and updates the project monthly. It announces the potential problem area in the
    claim submission.

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