D Bing D Kaplan: Electronic He Kaplan: Electronic He Instructions 1. Medicare Me
ID: 122926 • Letter: D
Question
Explanation / Answer
1.Different parts of Medicare cover different services. You may hear about four parts of Medicare: Part A, Part B, Part C, and Part D.
1b. Procedures/services covered by Medicare:
• Screening mammography
• Medical nutrition therapy
• Vaccines
• Physician services performed in conjunction with an eye disease (for example, glaucoma and cataract)
• x-ray
1c. Medicare doesn't cover everything. If you need certain services Medicare doesn't cover, you'll have to pay for them yourself unless you have other insurance or you're in a Medicare health plan that covers them.
Even if Medicare covers a service or item, you generally have to pay your deductible, coinsurance, and co-payments.
Medicare coverage of dental care:
Medicare doesn't cover routine dental care, such as oral examination, cleanings, fillings, bridges, or crowns. However, there are a few situation where you may be covered for dental services:
• Dental services may be covered if they are an essential part of another Medicare-covered procedure. For example, if you hurt your jaw in an accident, Medicare may cover jaw reconstruction if it is medically necessary to treat your injury.
• Medicare may cover extraction of teeth to prepare the jaw for radiation treatment for jaw-related neoplastic diseases.
• Medicare may cover dental examinations prior to a complicated procedure (such as a kidney or heart transplant) that requires an oral examination. You'll be covered under Medicare Part A or Part B, depending on whether the oral examination is performed in an inpatient or outpatient settings.
1d. Stipulations that exists on coverage of a service or procedure?
Medicare coverage of any kind for nursing care is very limited and largely based on medical necessity. If you’re in a care facility, Medicare covers so-called “skilled care” what’s performed by a medical professional. Custodial care (such as bathing, feeding and helping patients in and out of bed) is only covered while you also need skilled care. Custodial and skilled care are only covered for a limited time. Medicare pays all costs for the first 20 days after a qualifying medical event, but charges $157.50 in coinsurance for days 21 to 100, and nothing after that.
2. Medicare Part A covers nursing care facilities only if skilled nursing care (like changing surgical dressings) is necessary. If you need custodial care the routine care that sends most seniors to nursing homes will not be covered by Medicare.
Nursing care is the most essential part of health care that is necessary for all the patient whether in or out or at home or at centres. This service coverage limitations are inappropriate on medicare stipulations. All kinds of nursing care should or must be covered by medicare.
3.Medicare Part B (Medical Insurance) covers medically necessary diagnostic and treatment services you get as an outpatient from a Medicare-participating hospital. Covered outpatient hospital services may include:
• Emergency or observation services, which may include an overnight stay in the hospital
• Services in an outpatient clinic, including same-day surgery
• Laboratory tests billed by the hospital
• Mental health care in a partial hospitalization program, if a doctor certifies that inpatient treatment would be required without it
• X-rays and other radiology services billed by the hospital
• Medical supplies, like splints and casts
• Preventive and screening services
• Certain drugs and biologicals that you wouldn’t usually give yourself. Generally, Part B doesn't cover prescription and over-the-counter drugs you get in an outpatient setting, sometimes called “self-administered drugs." Also, for safety reasons, many hospitals have policies that don’t allow patients to bring prescription or other drugs from home.
Reimbursement process of different health insurance plans:
The healthcare reimbursement system is an extremely complex framework of obtaining payment for services. One of the most problematic issues is that the “rules” governing healthcare reimbursement change frequently, with government payers sometimes changing on a day-to-day basis.
Health insurance payers have a variety of healthcare reimbursement plans, and carry contracts with individual practices and health systems (contracts that are periodically renegotiated, which is just one source of change within the system). This means that there can be one price for services that occur within a health care system that’s contracted with a payer and another price for services that occur outside that system.
Examples include the application of a “claim edit” that eliminates payment for the administration of a vaccine when the physician bills for the vaccine itself or a “payment rule” that reduces the payment when the physician performs more than on procedure during the same visit. The payer then pays the physician the difference between this payer-calculated “total allowed amount” for the medical services and procedures and the amount owned by the patient.
That’s confusing enough. But the phrase “the amount owed by the patient” refers to yet another level of complexity in the healthcare reimbursement system, regarding the determination of which party is responsible for what portion of the amount charged for a service. How much is the responsibility of the patient? How much is the responsibility of the insurer? This can come down to the particular plan for which the individual, or the company the individual works for, has contracted with the payer.
This complexity can make it very difficult for practices to understand payer rules, keep up with changes to those rules, and stay ahead in the fast-moving healthcare reimbursement world. This is an area in which a cloud-based medical billing system, which can be updated continually and simultaneously for all practices, provides a tremendous advantage.
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