Medicare and Medicaid: What's the Difference?

Posted by:  :  Category: Medicare

Costs to Consumer: You must pay a yearly deductible for both Medicare Part A and Part B, and make hefty copayments for extended hospital stays. Under Part B, you must pay the 20% of doctors’ bills Medicare does not pay, and sometimes up to 15% more. Part B also charges a monthly premium. Under Part D, you must pay a monthly premium, a deductible, copayments, and all of your prescription drug costs over a certain yearly amount and up to a ceiling amount, unless you qualify for a low-income subsidy.
Source: nolo.com

What is the difference between Medicare and Medicaid?

Medicare is an insurance program. Medical bills are paid from trust funds which those covered have paid into. It serves people over 65 primarily, whatever their income; and serves younger disabled people and dialysis patients. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. Medicare is a federal program. It is basically the same everywhere in the United States and is run by the Centers for Medicare & Medicaid Services, an agency of the federal government.
Source: hhs.gov

Medicare Coverage Part A, B, C and D

Posted by:  :  Category: Medicare

Exams and checkups:  Medicare doesn’t cover routine physical exams. But when you’re new to Medicare, you’re entitled to a one-time “Welcome to Medicare” exam and medical history review within 12 months of enrolling in Part B. Also, Medicare now offers annual wellness checkups.  Both are free of charge if provided by a doctor who accepts Medicare reimbursement in full. Early detection:  Certain lab tests and screenings used to diagnose diseases early are also free of charge.  These include mammograms, pap smears, bone density measurement, and screenings for cardiovascular disease, prostate cancer, HIV and diabetes. Although the tests themselves are free, in most cases you still pay the required copay to see the doctor who prescribes them. 
Source: aarp.org

Medicare covers yoga for heart disease

“The reason that I spent 16 years working with the Centers for Medicare and Medicaid Services to achieve Medicare coverage for our program is that I knew that most insurance companies follow Medicare’s lead. In other words, if Medicare covered our program, most other insurance companies would, as well,” explains Ornish, who also says he was once naive in thinking that solid science alone would be enough to change health care policy.
Source: cnn.com

What is covered by Medicare?

Medicare is the basis of Australia’s health care system and covers many health care costs. You can choose whether to have Medicare cover only, or a combination of Medicare and private health insurance. Citizens and most permanent Australian residents are eligible for Medicare.
Source: gov.au

2016 Kansas Medicare Part D Prescription Drug Plan Highlights www.Q1Medicare.com

Posted by:  :  Category: Medicare

Coverage Gap the Donut Hole: In the CMS Standard Plan, the beneficiary must pay the next $3752.5 in drug costs (the Donut Hole). The Healthcare Reform provides that for Plan Year 2016, ALL formulary generics will have at least a 42% discount and ALL brand drugs will have at least a 55% discount in the coverage gap. The Gap Coverage Types discussed in this section are in addition to the Healthcare Reform mandated discounts. In our chart, you will see one of the following:
Source: q1medicare.com

Senior Health Insurance Counseling for Kansas (SHICK)

Senior Health Insurance Counseling for Kansas (SHICK) is a free program offering Kansans an opportunity to talk with trained, community volunteers and get answers to questions about Medicare and other insurance issues. SHICK provides you with many resources that will help you with your questions about Medicare.
Source: ks.gov

Kansas Senior Medicare Patrol

The Kansas Senior Medicare Patrol (SMP) is a statewide project designed to reduce Medicare and Medicaid fraud, waste or abuse. Through education, outreach, one-on-one assistance and problem resolution, Medicare and Medicaid beneficiaries are educated and counseled on how to protect themselves and identify and report scams and healthcare fraud or abuse. The Kansas SMP trains volunteers to assist with educating consumers. For SMP Additional Resources, click here. You can also find a list of Frequently Asked Questions by clicking here. Other helpful publications can be found under Senior Medicare Patrol on the Publications and Reports page.
Source: ks.gov

Medicare and Medicaid: What's the Difference?

Posted by:  :  Category: Medicare

Costs to Consumer: You must pay a yearly deductible for both Medicare Part A and Part B, and make hefty copayments for extended hospital stays. Under Part B, you must pay the 20% of doctors’ bills Medicare does not pay, and sometimes up to 15% more. Part B also charges a monthly premium. Under Part D, you must pay a monthly premium, a deductible, copayments, and all of your prescription drug costs over a certain yearly amount and up to a ceiling amount, unless you qualify for a low-income subsidy.
Source: nolo.com

Medicaid and Medicare Eligibility

Medicare has relatively basic general eligibility requirements to which a few stipulations are attached. American citizens and legal immigrants who are aged 65 years or older, younger than 65 but disabled or diagnosed with end-stage renal disease are also eligible for Medicare. Provisions apply to those aged 65 years or older. These individuals are eligible if they or a spouse spent at least 10 years working for a company that levied Medicare taxes. Some citizens under the age of 65 may be eligible to begin receiving Medicare benefits. To be eligible for early Medicare benefits, you must have been receiving Social Security or Railroad Retirement Board benefits for 24 months or previously worked in a Medicare-covered government job.
Source: essortment.com

Medicare Supplement Insurance Quote Engine

Posted by:  :  Category: Medicare

In addition to Medicare supplement insurance, we are pleased to be participating in the Medicare Advantage market. The Medicare Advantage policy is a low cost alternative to a Medicare supplement policy and is especially advantageous for those less than 65 years old. The Private Fee For Service (PFFS) is a type of Advantage plan that allows Medicare recipient to visit any doctor, any hospital, anywhere. Therefore, many Medicare recipients are well served by the lower cost Private Fee For Service plan.
Source: bestmedicaresupplement.com

Best Medicare Supplement Insurance Quotes

Every Medicare supplemental insurance plan must follow federal and state laws designed to protect you. Medicare supplement plan insurance companies can only sell you a “modernized” Medicare supplemental insurance plan identified by letters A through N. Each modernized Medicare supplemental insurance plan must offer the same basic benefits, no matter which insurance company sells it.
Source: medicaresupplementplans.com

Which Medicare Supplement is the best?

Coverage: Do you want more cost sharing for lower premiums or do you want a policy that covers all the deductibles, coinsurance and copays that are left for a Medicare beneficiary to pay.  A Medigap Plan F is the most comprehensive plan on the market and usually will be the most expensive plan available, but it does provide security that any catastrophic incidents would be covered.
Source: medicareinsurancefinders.com

Which Medicare Supplement Plans are the Best?

Introduced in 1965, Medicare was designed to provide affordable and reliable health care services to senior citizens and people with disabilities. Individuals who were eligible for Medicare faced significant financial struggles in paying for health insurance through the private sector. Medicare Part A does not include a monthly premium, which does provide some relief for seniors and people with disabilities. However, Part A has limited coverage for hospital expenses and skilled nursing facility care.
Source: medigapplansguide.com

Medicare Supplement Plans & Quotes

Turning 65 is stressful, and the amount of information people receive leading up to their birthday is astounding. From the stacks of mail piling up on your desk, to the seemingly endless phone calls and quotes from insurance companies and agents, the task of gathering honest, unbiased information can feel impossible. Our goal is to offer what nobody else will, which is why we provide medicare supplement quotes, financial ratings, benefit information, application fee data, price history, and pricing methodology for all supplemental insurance companies in one clean, concise report. Our free, no obligation service is designed to give you the information you need regarding Part D and Medicare Supplement Plans in order to make an educated purchasing decision. In addition, we offer continued support for all of our customers to ensure they have no claims or billing issues. On an annual basis we review all medicare supplement insurance quotes and plan options in an effort to notify our customers of any new or better plans that may be available.
Source: medicaresupplementshop.com

Medicare Supplement Insurance

The Part A hospital deductible – you’re responsible for paying a deductible if you are admitted into the hospital. In 2014 this deductible is $1184. Many people think that this is a one time or a annual deductible and it is not. This deductible is based on benefit periods of 60 days. This means if you are admitted to the hospital and then released and you stay out of the hospital for 60 days or more, that is considered one benefit period. If you are admitted again after that 60 day period you must pay this deductible again.
Source: medisupps.com

Medicare Appeals Process Forms

Posted by:  :  Category: Medicare

A party may appoint any individual, including an attorney, to act as his or her representative to help the party during the processing of a claim or claims and /or any appeals of claims. A representative may be appointed at any time during the appeals process. The party making the appointment and the individual accepting the appointment must either complete an appointment of representative form (CMS-1696, CMS-1696 Spanish) or use a conforming written instrument. If the form CMS-1696 is not used, the written request must contain all of the elements listed in 42 CFR 405.910. The appointment of representative is valid for one year from the date it is signed by both the party and the appointed representative. A detailed explanation of appointment of a representative can also be found in the CMS Internet Only Manual (IOM) 100-4, Chapter 29, section 270.
Source: findacode.com

Sterling Heights, Michigan Appeal Attorney :: The Audit Appeals Process :: Warren, Michigan Appellate Lawyer

Note: As with the redetermination level of appeal discussed above, the reconsideration level of appeal has a separate deadline that must be met in order to avoid recoupment of alleged overpayments by the CMS contractors. Specifically, recoupment can be stopped if the request is received by the CMS contractor within 60 days following the date of redetermination. If the request for reconsideration is not received by the CMS contractor within 60 days of the redetermination decision, recoupment can begin on day 76. It is also important to note that providers must present all evidence at the reconsideration level of appeal. If information is not submitted prior to the issuance of the Reconsideration decision, the provider will be precluded from presenting any additional evidence at the later stages of appeal unless the provider can demonstrate that it had “good cause” for failing to submit the information at the Reconsideration level.
Source: racattorneys.com

Medicare Part C Appeals > Home

Attention Medicare Health Plans- Updated Medicare Advantage Process Manual, Appendix, Reconsideration Background Data Form, and Dismissal Case File Data Form are now available under the ‘Health Plans’ section. Plans should begin using the new Reconsideration Background Data Form for appeals submitted to MAXIMUS Federal Services effective 1/1/2015. For dismissal review cases files submitted to MAXIMUS upon request after 1/1/14, health plans must use the Dismissal Case File Data Form.
Source: medicareappeals.com

Coventry Medicare: Grievances & Appeals

How do I submit a Part C Organization Determination to request coverage for medical services? You, your doctor, or representative can call, fax or mail your request to us. Phone and Fax: Our contact information (phone number, address, and fax number) is available to you on the contact us page of this website and in the plan’s Evidence of Coverage (EOC). You can also call us using the number on the back of your ID card. Fax: 855-788-3994 Mail: Part C Appeal & Grievance P.O. Box 7776 London, KY 40742-7776 What can I do if my Part C Organization Determination request is denied? If we don’t cover or pay for your benefits or services, you, your doctor, or representative can appeal our decision. You need to submit your name, address, member number and reason for appealing. Any evidence you want us to review, such as medical records, doctor’s letter or other information that explains why you need the item or services, can be submitted. Call your doctor if you need this information . For a standard appeal, mail or fax deliver your appeal to: Part C Appeal & Grievance P.O. Box 7776 London, KY 40742-7776 Fax: 855-788-3994 For an expedited appeal: Phone: 866-613-4977 Fax: 855-788-3994 How do I submit a Coverage Determination for my prescription drug? You, your doctor, or representative can submit the online form, or download the form for your type of plan, and fax or mail deliver your request to us. You may also call us. Submit online form If we don’t currently cover your medication or you need prior authorization before we cover your medication, you can ask for this coverage by completing one of the forms below: First Health Part D Prescription Drug Plans Medicare Advantage Plans Fax: 1-800-639-9158 Mail: Part D – Medicare Appeals & Grievances P.O. Box 7773 London, KY 40742 Phone: Our phone numbers (standard and expedited) are on the contact us page of this website, in the plan’s Evidence of Coverage (EOC), and on your ID card. What can I do if my Coverage Determination is denied? If we deny your Prescription Drug request, you can appeal our decision. You, your doctor, or representative can submit the online form, or download the form below and mail or fax deliver it to us. Submit online form Download: Request for Redetermination of Medicare Prescription Drug Denial Fax: 1-800-535-4047 Mail: Part D Medicare Appeals & Grievances – Redeterminations P.O. Box 7773 London, KY 40742 If your request needs to be “Expedited” you can call or fax us. Expedited Phone Line: 1-800-536-6167 Expedited Fax Number: 1-800-535-4047 What can I do if I have a complaint (also called a “grievance”)? If you have a complaint about your medical or pharmacy coverage, you, your representative , or your doctor can call, fax, or write to us. For Part C Appeal and Grievance: Phone : Our phone numbers are on the contact us page of the website, in the plan’s Evidence of Coverage (EOC), and on the back of your Member ID card. Mail: Part C Appeal & Grievance P.O. Box 7776 London, KY 40742-7776 Fax #: 855-788-3994 For Part D Appeal & Grievance: Phone : Our phone numbers are on the contact us page of the website, in the plan’s Evidence of Coverage (EOC), and on the back of your Member ID card. Fax #: 1-800-535-4047 Mail: Part D Appeal & Grievance P.O. Box 7773 London, KY 40742 You can contact the Office of the Medicare Ombudsman for help with a complaint, grievance, or information request. To learn more, visit http://www.cms.gov/Center/Special-Topic/Ombudsman-Center.html?redirect=/center/ombudsman.asp. How long does it take to get a decision? You can request either a “Standard” or “Expedited” (fast) decision process. If your health requires it, you can ask us to give you a "fast coverage decision". A "fast coverage decision" is called an "expedited coverage determination" or an “expedited organization determination”. When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. We will respond to your request no later than the below timeframes. Request for an Coventry Medicare Advantage Plan (Part C) Organization Determination  Standard Process = Pre-service: 14 days     Claims: 60 days Expedited Process = Pre-service: 72 hours     Claims: n/a Request for a Coventry Medicare Advantage Plan (Part C) Organization Determination Denial Standard Process = Pre-service: 30 days Claims: 60 days Expedited Process = Pre-service: 72 hours Claims: n/a Request for Prescription Drug Coverage Determination Standard Process= 72 hours Expedited Process= 24 hours Request for Redetermination for a Coventry Medicare Prescription Drug Denial Standard Process= 7 days Expedited Process= 72 hours Coventry Medicare Advantage Plan Grievance Standard Process= 30 days Expedited Process= 24 hours Prescription Drug Plan Grievance Standard Process= 30 days Expedited Process= 24 hours
Source: coventryhealthcare.com

SSA’s Appeals Council Review Process in ODAR

The Appeals Council looks at all requests for review, but it may deny a request if it believes the hearing decision was correct. If the Appeals Council decides to review your case, it will either decide your case itself or return it to an administrative law judge for further review. When the Appeals Council reviews your case it may consider any of the issues considered by the administrative law judge, including those issues that were favorably decided in your case. You will receive a copy of the Appeals Council’s final action on your case.
Source: socialsecurity.gov

​UPMC’s Medicare Advantage Provider Contracts with Highmark Will Not Be Extended for 2016

Posted by:  :  Category: Medicare

Nearly a year ago, however, Highmark stopped paying UPMC the rates specified in those contracts for that world-class care—including treatment for cancer at the renowned Hillman Cancer Center—and claimed that it has the right to reduce rates whenever and however it wishes. Although UPMC gave Highmark more than sufficient opportunity to take the required corrective actions, it has refused. As a result of Highmark’s breach of its UPMC contracts, and in keeping with UPMC’s right to end the contracts at the end of each calendar year with or without cause, UPMC has provided Highmark with notices of non-renewal of the current Medicare Advantage contracts effective January 1, 2016. No responsible organization could enter into—let alone extend—such illusory and one-sided contracts.
Source: upmc.com

Highmark: Your Health Care Partner

Highmark Inc. is a national, diversified health care partner serving members through its businesses in health insurance, dental insurance, vision care and reinsurance. Our mission is to make high-quality health care readily available, easily understandable and truly affordable in the communities we serve.
Source: highmark.com

Judge rules UPMC must accept Highmark Medicare Advantage members

While Highmark spokesman Aaron Billger said the Pittsburgh insurer was pleased the court agreed with state regulators “that UPMC cannot walk away from 182,000 seniors in our community,” UPMC spokesman Paul Wood said the health system will appeal the order and is “confident the Commonwealth Court’s order will be reversed.”
Source: post-gazette.com

Highmark, UPMC Medicare Advantage decision possible in weeks

If UPMC wins, the region could see less competition and less generous benefit plans in the Medicare Advantage market, said James Donahue, executive deputy attorney general for Pennsylvania. The program allows private insurers to design and administer Medicare benefit plans. About 1 million seniors and people with disabilities are signed up in Pennsylvania, according to the Kaiser Family Foundation.
Source: post-gazette.com

Coventry Medicare: Advantra (HMO

Posted by:  :  Category: Medicare

Whether you are an employer, health care provider, interested in enrolling, or already a member, our goal is to provide you with valuable and convenient online resources and information. Come explore the ways in which we can help you take charge of your Medicare Advantage coverage.
Source: coventryhealthcare.com

Medicare Plans for Different Needs

Your health is important. Find a UnitedHealthcare Medicare Advantage plan or Medicare prescription drug plan that may be right for you before Open Enrollment ends December 7. With a Medicare Supplement Insurance plan* you may apply at any time throughout the year.  
Source: uhcmedicaresolutions.com

Compare Medicare Supplement Insurance Plans & Medigap Plans and Rates for
2011. See Plan Chart for AL, AR, AZ, CO, FL, GA, IA, ID, KS, KY, LA, MD, MI, MO, MN, MS,
NC, NE, NM, OH, OK, SC, TN, TX, VA & WV. Medigap Insurance Plans including the
Popular Plan F & G

Year after year we have found Medicare Supplement Plan F or Medicare Supplement Plan G to be the best value for the dollar. The new Plan N is a great alternative to a Medicare Advantage plan.  Plan N might be recommended depending on which state you live in and how much the supplement cost in relation to available Medicare Advantage plans. A plan N will provide more coverage and a very reasonable premium. In Florida we have the lowest rate for plan F & plan N. See the Medicare Supplement Plan chart below. In general, the higher you go up in the plan chart the more Gaps the plan fills. Medicare Supplement Plan F is the most comprehensive supplement plan and there is not a better plan than F. Most people will select a Plan F. However, depending on your personal situation there may be a more cost efficient choice.
Source: themedicarechannel.com

2016 Georgia Medicare Part D Prescription Drug Plan Highlights www.Q1Medicare.com

Coverage Gap the Donut Hole: In the CMS Standard Plan, the beneficiary must pay the next $3752.5 in drug costs (the Donut Hole). The Healthcare Reform provides that for Plan Year 2016, ALL formulary generics will have at least a 42% discount and ALL brand drugs will have at least a 55% discount in the coverage gap. The Gap Coverage Types discussed in this section are in addition to the Healthcare Reform mandated discounts. In our chart, you will see one of the following:
Source: q1medicare.com

Medicare Information for Retirees

Annuitants and certain individuals on subsidized extended coverage age 65 or older who wish to pay subsidized rates for health insurance premiums must enroll in the Medicare Advantage (MA) PPO Standard or Premium option offered by Blue Cross Blue Shield of Georgia (BCBSGa).  See Plan Documents for rate resolutions and annuitant subsidy policies.
Source: georgia.gov

Medicare Supplemental Insurance

Finding the best Medicare Supplemental insurance, Medicare Advantage, and Medicare Part D has gotten more complicated nearly every year. In 2010 Medicare Supplement Insurance added 2 new plans Medigap plan N and Medigap Plan M. At the same time they eliminated several other Medicare Supplement options. Medicare Advantage insurance plans redefine benefits and premiums every year. And, with future Medicare subsidies uncertain due to changing regulation from healthcare reform who can keep up. For many individuals Medicare Supplement Insurance is becoming the best option. Unfortunately, comparing Medicare Supplemental Insurance Plan premiums (Medigap) and Medicare Advantage plans can be a time consuming endeavor. Our highly trained insurance advisors can explain all of your supplemental Insurance options, and assist in finding the best Medicare supplement and Medicare Part D combination that best fits your specific needs. With all the options affecting Supplement insurance and Part D it makes sense to have an expert assist you through the maze.
Source: mysenioradvisorsgroup.com

Medicare Supplement and Medicare Advantage Plans in Texas

Posted by:  :  Category: Medicare

From Houston to Plano, San Antonio to Corpus Christi, Dallas/Ft. Worth to Austin, El Paso to Arlington, Amarillo, Beaumont, Brownsville, Denton, Frisco, Garland, Irving, Laredo, Lubbock, Pasadena or Waco it is important that you find the medicare coverage that fits your life and your lifestyle. We feel that the best care is received when you have your choice of Doctors, and you and your Doctor make your medical decisions. Medigap plans in Texas are available with no medical underwriting during your initial enrollment period. This is when you become eligible for Medicare Part B. You may however, apply to a company and fill out the medical underwriting questions at any time. We are pleased to introduce our Texas Medicare Supplement Comparison Quoting System. It is a very simple process where you enter a few bits of information and then we will quote all of the medicare supplement plans offered by several companies. The companies that we select to quote are based on their strong reputations and competitive pricing. Some of the companies that we represent are: Aetna, BlueCross BlueShield of Texas, Combined Insurance, Equitable Life, Heartland National, Omaha Insurance Company, Standard Life & Casualty, UCT, United American and UnitedHealthcare
Source: medicare-texas.net

Medicare Prescription Drug Coverage (Medicare Part D)

Medicare sets standard costs for the prescription drug benefit each year. Private companies approved by Medicare offer plans with different costs and selections of prescription drugs. You can select a plan based on the prescriptions you take and select a company that is most effective for you. To reduce your costs, enter your medications on Medicare’s secure online Find health and drug plans website. You will pay more if your prescriptions are not in the plan formulary or the plan restricts or limits their use.
Source: texas.gov

Enroll Today for Texas Medicare Plans

If you’re eligible for Medicare, we invite you to learn more about Allegian Advantage Plans— Texas Medicare Advantage Plan. With Allegian Advantage,you get more benefits than Original Medicare at no extra cost to you, and no monthly premium. We serve Medicare-eligible Texans in Hidalgo, Willacy and Cameron counties as well as El Paso and Bexar Counties effective 1/1/2016.
Source: allegianadvantage.com

Texas Medicare Part D & Medicare Advantage Plans

Choosing a Texas Medicare Part D plan that fits your circumstances is very important as there are many plans to choose from. Texas Medicare Part D plans are offered by private insurance companies so there are plans with different deductibles, copays and premiums. Before you choose a Medicare Part D plan in Texas you should determine your annual out-of-pocket expenses for prescription medications. Make sure the Texas Medicare Part D plan you select covers all of your prescriptions. You should consider the copays, deductibles and premiums of each plan to determine which Medicare Part D plan offers the most savings. You can compare Texas Medicare Part D plans by using the PlanPrescriber Medicare Part D plan comparison tool to find a plan in Texas that works for you.
Source: mytexasmedicare.net

Opting Out of Medicare: a guide for physicians

Posted by:  :  Category: Medicare

I, ______, declare under penalty of perjury that the following is true and correct to the best of my knowledge, information, and belief: 1. I am a physician licensed to practice medicine in the state of ______. My address is at _________, my telephone number is _________, and my [national provider identifier (NPI) or billing number, if one has been assigned, uniform provider identification number (UPIN) if one has been assigned, or, if neither an NPI nor a UPIN has been assigned, my tax identification number (TIN)] is _________. I promise that, for a period of two years beginning on the date that this affidavit is signed (the “Opt-Out Period”) and continuing indefinitely with automatic extensions of the 2-year opt out period unless terminated by me as allowed by Title 1 Section 106(a)(1) Medicare Access and CHIP Reauthorization Act of 2015, I will be bound by the terms of both this affidavit and the private contracts that I enter into pursuant to this affidavit. [NOTE: Your personal UPIN number must be used, not a corporate UPIN number. Persons opt out, not corporations.] 2. I have entered or intend to enter into a private contract with a patient who is a beneficiary of Medicare (“Medicare Beneficiary”) pursuant to Section 4507 of the Balanced Budget Act of 1997 for the provision of medical services covered by Medicare Part B. Regardless of any payment arrangements I may make, this affidavit applies to all Medicare-covered items and services that I furnish to Medicare Beneficiaries during the Opt-Out period, except for emergency or urgent care services furnished to Beneficiaries with whom I had not previously privately contracted. I will not ask a Medicare Beneficiary who has not entered into a private contract and who requires emergency or urgent care services to enter into a private contract with respect to receiving such services, and I will comply with 42 C.F.R. § 405.440 for such services. 3. I hereby confirm that I will not submit, nor permit any entity acting on my behalf to submit, a claim to Medicare for any Medicare Part B item or service provided to any Medicare Beneficiary during the Opt-Out Period, except for items or services provided in an emergency or urgent care situation for which I am required to submit a claim under Medicare on behalf of a Medicare Beneficiary, and I will provide Medicare-covered services to Medicare Beneficiaries only through private contracts that satisfy 42 C.F.R. § 405.415 for such services. 4. I hereby confirm that I will not receive any direct or indirect Medicare payment for Medicare Part B items or services that I furnish to Medicare Beneficiaries with whom I have privately contracted, whether as an individual, an employee of an organization, a partner in a partnership, under a reassignment of benefits, or as payment for a service furnished to a Medicare Beneficiary under a Medicare+Choice plan, during the Opt-Out Period, except for items or services provided in an emergency or urgent care situation. I acknowledge that, during the Opt-Out Period, my services are not covered under Medicare Part B and that no Medicare Part B payment may be made to any entity for my services, directly or on a capitated basis, except for items or services provided in an emergency or urgent care situation. 5. A copy of this affidavit is being filed with [the name of each local Medicare carrier], the designated agent of the Secretary of the Department of Health and Human Services, no later than 10 days after the first contract to which this affidavit applies is entered into. [FOR PARTICIPATING PHYSICIANS ONLY: My Medicare Part B Participation agreement terminates on the effective date of this affidavit.] Executed on [date] by [Physician name] [Physician signature]
Source: aapsonline.org

The Six Main Reasons Physicians Are Dropping Medicare Patients

Bureaucratic Nightmare It was difficult enough prior to the Affordable Care Act (ACA) for a physician to document a patient file sufficiently to satisfy CMS that prescribed care was correct and properly coded. The ACA continues the steady march toward even more arcane bureaucratic “metrics” which take into account “patient outcomes” and effectiveness of treatment before payment can be sought. An entire cottage industry has sprung up, offering sophisticated computer systems and processes, aimed solely at making the documentation of treatment — not the treatment itself — more satisfying to CMS. This bureaucracy is no better exemplified than by reference to the list of acronyms on the CMS website: 198 Medicare acronyms – and that’s just the ones which begin with the letter “R.” RAC Auditors As complex as documentation rules can be, payment of a claim by CMS was often the only way a physician could be sure he or she got it right. Getting paid is just the beginning. In 2003, the government began unleashing an army of Recovery Audit Contractors (RACs). RAC auditors are supposed to review patient files and billing records to identify both over- and under-payments. Not surprisingly, given that RAC auditors are compensated a percentage for finding over-payments, 97 percent of RAC findings favor the government. This means physicians must return payments, long after the claim has been paid, often because a non-physician auditor with a financial interest in contradicting the physician has overruled the doctor.
Source: physicianspractice.com

Medicare Patients’ Access to Physicians: A Synthesis of the Evidence

Nationally, patient and physician surveys and Medicare’s administrative data show that most Medicare patients enjoy good access to physicians and most physicians are accepting new Medicare patients.  Moreover, survey findings reveal that Medicare beneficiaries and adults with private insurance report similar access to physicians. While the majority of Medicare beneficiaries report having a usual source of care and do not forego needed physician visits, certain subgroups of Medicare beneficiaries have higher rates of access problems that warrant close attention. These include beneficiaries with no supplemental insurance or Medicaid, beneficiaries under age 65 living with a permanent disability, beneficiaries in fair and poor health, beneficiaries with four or more chronic conditions, and beneficiaries with lower incomes. For the most part, however, even among these subgroups, most do not report significant problems securing access to medical care when needed. Physician surveys and Medicare data tell a complementary story to the patient surveys.  Overall 91 percent of physicians report taking new Medicare patients—comparable to the rate for new private non-capitated patients. About 1 percent of physicians have formally opted-out of the Medicare program to contract privately with all their Medicare patients, with psychiatrists comprising the largest share.  Factors that influence physician decisions about acceptance of new patients can be strongly influenced by local health market circumstances that cannot be ascertained from state-level data.  Further research is needed at a more local level to understand how access is affected by other factors including provider supply, other insurer interactions, changes in group practice dynamics, and patient demand for medical services. Survey instruments could be improved to determine if doctors in open practices access some or all new patients, by type of insurance. While this paper focuses mostly on physicians, the number of other health professionals who provide care to Medicare patients—such as nurse practitioners and physician assistants—has grown rapidly over the past decade.
Source: kff.org

Avoid Medicare Fraud Claims by Coding Correctly

You may believe you are beyond reproach if you don’t order a mobile scooter for every patient or dump your patient records in the nearest landfill, but you should exercise caution in these cautionary times: what the feds consider “fraud” is much broader than your definition. E&M coding, for instance is a potential target; the 99213 and 99214 office follow-up codes were the top two CPT codes in terms of both charges and unit volume in 2010. Don’t let your practice be caught up in Medicare’s recovery program. It’s a simple matter to examine your own coding patterns and compare them to national utilization data collected by Medicare. Knowing how you compare to others within your specialty is important in assessing possible exposure to recovery efforts.
Source: physicianspractice.com

Physicians for a National Health Program

The Affordable Care Act will add more than a quarter of a trillion dollars to the already very high administrative costs of U.S. health care through 2022, according to a study published Wednesday at the Health Affairs Blog.
Source: pnhp.org