What is “Usual, Customary and Reasonable-UCR payment ?

Carla and Nora went to the same hospital and are covered by the same
insurance company. Both ladies are out-of-network for this hospital.

The only difference between the amount covered is set by where they live. Carla lives in CT while Nora resides in NY. Following the insurance company’s payment and two appeals on the basis of UCR** rates the CT based insurer issues additional payment, while the NY counterpart denies.
 

What happed to the rate calculation? Why does residence makes a difference? What is Usual, Customary and Reasonable (UCR) rate?

The hospital charged the same rate for both. The only difference is the regulatory authority each insurance department represents. UCR is

supposed to be the average rate a professional with like qualifications, training, and practice location charge for the same service.

If you must use an out of network provider be aware of the URC rates.

Definitions:

Out of network:

 
*Doctors, therapist whom decided not to participate in an insurance network.
 

Usual, Customary and Reasonable:
 

** A fee charged by medial professionals with similar training, experience and
geographic location.

Opted-out:

 
Doctors choose not to provide care for a Medicare regulated reimbursement rate.

Tips for scucessful Medicare provider enrollment process

Tips to Facilitate the Medicare Enrollment Process 

To ensure that your Medicare enrollment application is processed timely, you should:

1. Consider using Internet-based Provider Enrollment, Chain and Ownership System (PECOS) to enroll or make a change in your Medicare enrollment if it is available for your provider or supplier type.

2. Submit the current version of the Medicare enrollment application (CMS-855). 

The Centers for Medicare & Medicaid Services (CMS) revised the Medicare enrollment application (i.e., CMS-855A, CMS-855I, CMS-855B, and CMS-855R) in February 2008. CMS revised the DMEPOS supplier enrollment application (i.e., CMS-855S) in March 2009.

3. Submit the correct application for your provider or supplier type to the Medicare fee-for-service contractor servicing your State or location. 

The Medicare contractor that serves your State or practice location is responsible for processing your enrollment application. Applicants must submit their application(s) to the appropriate Medicare fee-for-service contractor. A list of the Medicare fee-for-service contractors by State can be found in the download section of www.cms.hhs.gov/MedicareProviderSupEnroll


.4. Submit a complete application. If you are enrolled in Medicare, but have not submitted the CMS-855 since November 2003, you are required to submit a complete application. Providers and suppliers should follow the instructions for completing an initial enrollment application.

5. Request and obtain your National Provider Identifier (NPI) number before enrolling or making a change in your Medicare enrollment information. 

CMS requires that providers and suppliers obtain their National Provider Identifier (NPI) prior to
enrolling or updating their enrollment record with Medicare.

6. Submit the Electronic Funds Transfer Authorization Agreement (CMS-588) with your enrollment application, if applicable. 

CMS requires that providers and suppliers, who are enrolling in the Medicare program or making achange in their enrollment data, receive payments via electronic funds transfer. Reminder: when completing the CMS-588 complete each section.

6.Submit all supporting documentation.

In addition to a complete application, each provider or supplier is required to submit all applicable supporting documentation at the time of filing. Supporting documentation includes, if applicable, an authorization agreement for Electronic Funds Transfer Authorization Agreement (CMS-588).

Note:Only durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers are required to submit the National Provider Identifier notification received from the National Plan and Provider Enumeration System.

7. Sign and date the application. 

Applications must be signed and datedby the appropriate individuals. Signatures must be original and in ink (blue preferable). Copied or stamped signatures will not be accepted.

8. Respond to fee-for-service contractor requests promptly and fully. 

To facilitate your enrollment into the Medicare program, respond promptly andfully to any request for additional or clarifying information from the fee-for-service contractor.

What are Bedsores?

Bedsores are lesions which are typically caused by periods of prolonged immobility. A mild bedsore can generally be easily treated, but more severe sores can cause serious problems, and they require surgical intervention. Bedsores strike people who are bedridden, paralyzed, or dealing with other limited mobility issues, and prevention of bedsores is a major part of training for health providers who deal with at-risk individuals.

These lesions are also known as pressure ulcers, decubitis ulcers, or skin ulcers. If left untreated, bedsores can cause sepsis, cellulitis, gangrene, and deep infections of the bones and joints. Bedsores have also been linked with carcinoma and necrotizing fasciitis, an infection which literally eats away otherwise healthy tissues. People in wheelchairs or people who are bedbound are at risk for skin ulcers, as are long-term hospital patients, individuals in nursing homes, and people with conditions such as diabetes, which interferes with circulation.

There are three primary causes for bedsores. The first is simply prolonged pressure, which can cause bedsores to appear on places like hips and shoulder blades. Bedsores also form through friction and shear as the patient's body rubs against a bed or wheelchair. Active people rarely get such sores because they make small adjustments to their position throughout the day and while they sleep. Someone who has a limited range of motion can get a bedsore in only a few hours if he or she is positioned in a way which cuts off circulation.

There are four different stages of bedsores. A stage one bedsore manifests as an area of tenderness and mild inflammation, and it generally vanishes shortly after the pressure on the area is relieved. A stage two bedsore is characterized by some skin loss, forming an open blister or wound which is also discolored; with rapid treatment, this type of sore generally heals quickly. Stage three bedsores are deeper, while stage four bedsores can be extremely deep fissures surrounded by dead tissue. A stage four bedsore is also characterized by damage to the underlying muscle and bone, and it represents a serious medical problem.

There are a number of ways to avoid bedsores. The first is frequent positional changes such as turning, accompanied by the use of supportive pads which can reduce pressure on problem areas like the hips. Caregivers also need to carefully inspect their patients for the early signs of bedsores, and patients generally benefit from nutritional support and physical therapy as well.

Medicare payment for physician and non physician

Medicare payment for services of nonphysician practitioners

Medicare pays for NPP services in one of three ways. First, NPPs may bill directly for their services under the physician fee schedule.6 In this case, NPPs or their employers receive a percentage of the fee s c h e d u l e payment. Second, services may be billed incident to physician services, in which case physicians bill for the services at 100 percent of the fee schedule payment, even though NPPs provided the services. Third, the services of NPPs may be included in the payment bundle for services provided in hospitals and skilled nursing facilities. The accompanying box provides additional detail on the first two payment paths.

Payment for nonphysician practitioners
Medicare payment for services provided by nonphysician practitioners depends on whether
the service is directly billed by the nonphysician practitioner under his or her own billing
number or billed “incident to” under the physician’s billing number.

Direct billing under the physician fee schedule
Before enactment of the Balanced Budget Act of 1997 (BBA), Medicare paid for services of nurse
practitioners (NPs) and clinical nurse specialists (CNSs) only when provided in rural settings, in
nursing facilities, or when assisting at surg e r y. Services were paid at 75 percent of the physician fee schedule amount when furnished in a hospital and at 85 percent of the fee schedule amount when furnished in other settings. Payments for assisting at surgery were 65 percent of the rates for physicians who assist at surg e r y. Finally, payment for services provided in an urban nursing home was made to the NP’s or CNS’s employer, rather than directly to the NP or CNS.

Physician assistant (PA) services—when provided under the supervision of physicians—were
covered in hospitals and nursing facilities and in physician offices in rural areas designated as health professional shortage areas. Services also were covered when the PA acted as a first assistant at s u rg e r y. Payments were made to the employer at 65 percent of the physician fee for assisting at s u rg e r y, 75 percent of the physician fee for services provided in a hospital, and 85 percent of the physician fee for services in other settings.

The BBAexpanded payment for services provided by NPs, CNSs, and PAs by removing restrictions on geographic areas and settings in which these providers could be paid by Medicare. The legislation also increased the payment for these providers to a uniform 85 percent of the physician fee schedule.

The BBA did not change payment policies for certified nurse-midwives (CNMs), who were not
subject to the same geographic and setting restrictions as the other nonphysician practitioners.
Services of CNMs are paid at 65 percent of the physician fee schedule.

Medicare also allows direct payment for some other nonphysician providers. Certified registered nurse anesthetists receive payment at 100 percent of the physician fee if not medically directed, but 50 percent if medically directed (in which case the anesthesiologist providing medical direction receives the other 50 percent). Physical and occupational therapists and clinical psychologists are reimbursed at 100 percent of the physician fee schedule. Clinical social workers are reimbursed at 75 percent of the physician fee schedule.

Billing incident to a physician service

Services provided by NPs, CNSs, PAs, and CNMs are paid at 100 percent of the physician fee
schedule if they are billed by the physician as incident to services in a physician’s office or clinic.
Incident to services must be provided by employees of a physician under the physician’s direct
supervision. In addition, the physician must be in the office suite while the service is being provided and be immediately available to provide assistance and direction. The physician also must have provided direct, personal professional services to initiate the course of treatment and must furnish subsequent services at a frequency consistent with active management of the course of treatment. Incident to billing is not allowed for the first visit for a new patient or for subsequent visits that present a new problem. In these cases, physicians must personally examine patients to bill for services at the physician rate; otherwise, services are billed at the nonphysician practitioner rate.

Payment for physician and non physician differnce

Should payment rates differ when services are provided by nonphysician practitioners instead of physicians?

The physician fee schedule does not differentiate among specialties in the payments provided for particular services, although payments for more complex services are higher to account for the additional time, eff o r t , skill, and stress that may be required to provide care. If payment rates adequately account for diff e r e n c e s in resource costs among services, paying different amounts for services when they are provided by NPPs may not be justified.

Whether payment rates should differ between physicians and NPPs depends on whether they produce the same product. The product can be characterized by the services provided, the locations in which they are provided, and the patient outcomes that result. The inputs used to produce a service also may diff e r, and this can affect the cost of the product. Inputs are the resources to provide the service: providers’ e d u c a t i o n and training; practice expenses, including support staff, office space, supplies, and equipment; and professional liability insurance. These inputs, along with the time, effort, skill, and stress required to provide the service, are the components used in the physician fee schedule to determine payment rates.

Some of these factors may justify a payment difference while others may not. On the one hand, data on the type of service, location of service, and outcomes provide evidence of many similarities between NPPs and physicians. On the other hand, some argue that differences in the length and content of training between NPPs and physicians support a payment differential. Consideration also should be given to d i fferences in rates for professional liability insurance between physicians and NPPs. Practice expenses, h o w e v e r, may be the same regardless of who provides the service.

Does the product vary by the type of practitioner?

To help assess whether physicians and nonphysician practitioners provide different products, MedPAC examined Medicare data on the types and location of services provided by NPPs. We also reviewed research on quality and patient outcomes and information on other payers. In general, NPPs provide more evaluation and management (E&M) services that are slightly lower in complexity than physicians on average. Both provide a majority of their services in office based settings, although NPPs tend to provide a higher proportion of their services to patients in nursing facilities. Outcomes of care provided by NPPs for equivalent patients have been shown to be comparable to those of physicians.

What payment will be paid by Medicare for Advanced Practice Nurses and Physician Assistants

Medicare Payment to Advanced Practice Nurses and Physician Assistants

Non physician practitioners in the health care workforce

NPPs represent a growing share of the health care provider workforce. The number of providers who are certified and practicing more than doubled over the past decade, from about 60,000 in 1992 to 124,000 in 2000 (AAPA2001, Spratley et al 2000, Sekscenski et al 1994, Moses 1992). In contrast, the number of active physicians grew 27 percent, to 772,000, over the same period (Cooper et al 2002). Currently, about 55,000 of these NPPs have Medicare provider numbers, which allow them to bill directly for Medicare services (Non-Physician Practitioner News 2002). In 2000, they provided about 8.5 million separately billed services to Medicare patients.

Because physicians also may bill (under their own provider number) for services provided by NPPs in their offices, information on the total number of services provided by NPPs is limited. According to one analysis, about 25 percent of primary-care office-based physicians used NPs or PAs during the 1995-1999 period. When NPs or PAs were used, they saw patients for an average of 11 percent of visits and in almost half of these visits the patient was not seen by a physician (Hooker and McCaig 2001). The use of NPs and PAs is much higher in rural areas. One study, for example, showed that NPs and PAs were present at 37 percent of rural outpatient hospital visits compared with only 5 percent of urban visits (Anderson and Hampton 1999).

PAs must be supervised by a physician, but CNMs, NPs, and CNSs may practice independently if state law allows. State regulation of CNMs, NPs, and PAs varies widely. Favorable practice environments are strongly associated with a larger supply of these practitioners (McCaig et al 1998, Sekscenski et al 1994).

Training programs for NPPs typically last two years and require prior health care experience. Training for CNMs, NPs, and CNSs is generally at the master’s level and requires a license as a registered nurse and b a c h e l o r’s degree (generally a bachelor’s of science degree in nursing). PAtraining can be at the certificate, a s s o c i a t e ’s, bachelor’s, or master’s level—although the majority of PAs have a bachelor’s degree before entering a training program—and most programs require prior experience in health care or a related field.

About 90 percent of NPs and 50 percent of PAs provide primary care (Hooker and McCaig 2001). CNMs focus on childbearing, family planning, and gynecological care for well women, although they also may assess and manage common acute episodic illnesses and care for newborns and infants up to one year of age. The majority of CNSs specialize in clinical psychiatry-mental health nursing or medical-surgical nursing, but others specialize in pediatrics, gerontology, community health, and home-health nursing.

Most services provided by NPPs are in the office setting, although NPs and CNSs provide substantial shares of their services in nursing homes. PAs perform a substantial share of their services in hospitals.

Medicare labaratory fee schedule history - From year 1984 - 1998

 Changes in the Medicare laboratory fee schedule.  Please check with your local Medicare. For current Medicare fee schedule .

Medicare Payment for Clinical Laboratory Services

Medicare consists of two parts: Medicare Part A covers inpatient hospitalization costs, once the annual deductible has been met, for almost everyone age 65 and older plus the permanently disabled and those with chronic renal disease. Coverage under Part A is automatic. Payment for inpatient care in most hospitals is based on a fixed fee determined for each diagnosis (diagnosis-related groups, DRGs). DRGs are not applied to physician services. Laboratory tests performed for Medicare inpatients are considered a part of the DRG payment. Medicare Part B covers physician services, outpatient clinical laboratory, and x-ray tests for eligible persons along with other medical services and supplies not covered under Part A. Part B is voluntary; however, most who are eligible sign up. There is an annual deductible and a 20% co-payment for all Part B services except outpatient clinical laboratory services.

Most clinical laboratory procedures are paid from laboratory fee schedules issued by individual Medicare carriers. Medicare carriers are contractors, usually large insurance companies, who administer Part B Medicare services in each state. There are 57 carriers, including one for each state and territory plus two in California and three in New York. All physician services, including pathology services not included in the laboratory fee schedule, are paid according to the Physician Fee Schedule. Unlike the laboratory fee schedule, under this schedule co-payments of 20% are collected from the beneficiary so that the actual payment received from Medicare for a given procedure is 80% of the Physician Fee Schedule amount.


Before Medicare pays for any test or diagnostic service, two basic criteria must be met: (a) the service must be covered by Medicare, and (b) the service must be medically necessary and indicated. Once these two criteria are met, Medicare pays for most clinical laboratory tests based on the applicable Laboratory Fee Schedule. Each carrier publishes a unique laboratory fee schedule and adjusts payment levels as determined by Congress during the annual budget process. Updates, when granted, are effective January 1st.


national fee limitations

National caps apply to most laboratory tests. These caps define the maximum amount a carrier may pay for a given test. The 1998 National Limitation amounts for any given test are based on 74% of the median amount listed on all carriers' fee schedules for a particular laboratory test. National caps were reduced from 76% to 74% effective January 1, 1998, resulting in a reduction of 2.63% for most clinical laboratory tests.

Fee schedules may be adjusted only by statutory changes approved by Congress. When the fee schedule is adjusted by a given percentage, national caps are adjusted up or down by the same amount. Medicare payment for clinical laboratory tests is always the lowest of the fee schedule, the national cap, or the actual amount billed. The changes shown in Table 1,have been made to laboratory fees since 1984, when the Laboratory Fee Schedule was established. The dollar amounts at the right-hand side of Table 1 show the effect of fee schedule changes on a test that was reimbursed at $10.00 in 1984.

Certain clinical diagnosis procedures listed in the Pathology and Laboratory sections of the Physicians' Current Procedural Terminology (CPT) are not considered a part of the laboratory fee schedule. The procedures listed below are paid from the Physician Fee Schedule at 80% of the amount listed on that fee schedule. The beneficiary is responsible for the remaining 20% once the annual deductible has been met. These procedures are not subject to national limitations:

    * Clinical pathology consultations
    * Bone marrow smears and biopsy
    * Blood bank physician services
    * Skin tests
    * Anatomical and surgical pathology services
    * Duodenal and gastric intubation
    * Sputum and sweat collection

Medicare tests must be billed on an assigned basis. This means that the provider must accept the Medicare reimbursement as payment in full for any covered laboratory test. Medicare patients may not be billed for any additional amounts for covered tests. (See below for policies regarding tests that are not covered by Medicare). Medicare patients may be billed for non-covered services. The mandatory assignment requirement for laboratory tests applies regardless of whether the physician is participating (accepts assignment for all Medicare services) or non-participating (does not accept assignment for all Medicare services).

Direct billing is also required for all Medicare-reimbursed laboratory tests. Tests must be billed directly to Medicare by the laboratory or physician performing the tests. If an outside laboratory performs a test on a referral from a physician, only the reference laboratory may legally bill Medicare for the procedure.

However, hospitals and reference laboratories that send specimens to other laboratories may bill Medicare for tests performed by the other laboratories if the referring laboratory meets any one of the following three exceptions:

    * (a) The referring laboratory is located in or is part of a rural hospital;
    * (b) The referring laboratory is wholly owned by the reference laboratory, or the referring laboratory wholly owns the reference laboratory, or both referring laboratory and reference laboratory are wholly owned by a third entity; or
    * (c) No more than 30% of the clinical diagnostic tests for which a laboratory receives requests annually are performed by another laboratory other than an ownership-related laboratory.

For the purpose of the 30% exception, each CPT code billed counts as one test. For example, when CPT code 80054 is billed, it is counted as one test although 12 tests are performed.

MCR - 835 Denial Code List

PR 1 Deductible Amount
PR 2 Coinsurance Amount
PR 3 Co-payment Amount
OA 4 The procedure code is inconsistent with the modifier used or a required modifier is missing.
OA 5 The procedure code/bill type is inconsistent with the place of service.
OA 6 The procedure/revenue code is inconsistent with the patient's age.
OA 7 The procedure/revenue code is inconsistent with the patient's gender.
OA 8 The procedure code is inconsistent with the provider type/specialty (taxonomy).
OA 9 The diagnosis is inconsistent with the patient's age.
OA 10 The diagnosis is inconsistent with the patient's gender.
OA 11 The diagnosis is inconsistent with the procedure.
OA 12 The diagnosis is inconsistent with the provider type.
OA 13 The date of death precedes the date of service.
OA 14 The date of birth follows the date of service.
CO 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
OA 16 Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
PI 17 Payment adjusted because requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
OA 18 Duplicate claim/service.
OA 19 Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
OA 20 Claim denied because this injury/illness is covered by the liability carrier.
OA 21 Claim denied because this injury/illness is the liability of the no-fault carrier.
CO 22 Payment adjusted because this care may be covered by another payer per coordination of benefits.
PI 23 Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments
CO 24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
PR 25 Payment denied. Your Stop loss deductible has not been met.
PR 26 Expenses incurred prior to coverage.
PR 27 Expenses incurred after coverage terminated.
CO 29 The time limit for filing has expired.
PR 31 Claim denied as patient cannot be identified as our insured.
PR 32 Our records indicate that this dependent is not an eligible dependent as defined.
PR 33 Claim denied. Insured has no dependent coverage.
PR 34 Claim denied. Insured has no coverage for newborns.
PR 35 Lifetime benefit maximum has been reached.
CO 38 Services not provided or authorized by designated (network/primary care) providers.
CO 39 Services denied at the time authorization/pre-certification was requested.
OA 40 Charges do not meet qualifications for emergent/urgent care.
OA 44 Prompt-pay discount.
CO 45 Charges exceed your contracted/ legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).
CO 49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
CO 50 These are non-covered services because this is not deemed a `medical necessity' by the payer.
CO 51 These are non-covered services because this is a pre-existing condition
OA 53 Services by an immediate relative or a member of the same household are not covered.
CO 54 Multiple physicians/assistants are not covered in this case .
CO 55 Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
CO 56 Claim/service denied because procedure/treatment has not been deemed `proven to be effective' by the payer.
CO 58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
OA 59 Charges are adjusted based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.)
CO 60 Charges for outpatient services with this proximity to inpatient services are not covered.
OA 61 Charges adjusted as penalty for failure to obtain second surgical opinion.
CO 66 Blood Deductible.
CO 69 Day outlier amount.
CO 70 Cost outlier - Adjustment to compensate for additional costs.
OA 74 Indirect Medical Education Adjustment.
OA 75 Direct Medical Education Adjustment.
CO 76 Disproportionate Share Adjustment.
CO 78 Non-Covered days/Room charge adjustment.
PR 85 Interest amount. This change effective 1/1/2008: Patient Interest Adjustment (Use Only Group code PR)
OA 87 Transfer amount.
CO 89 Professional fees removed from charges.
OA 90 Ingredient cost adjustment.
CO 91 Dispensing fee adjustment.
CO 94 Processed in Excess of charges.
OA 95 Benefits adjusted. Plan procedures not followed.
CO 96 Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
PI 97 Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated
OA 100 Payment made to patient/insured/responsible party.
CO 101 Predetermination: anticipated payment upon completion of services or claim adjudication.
CO 102 Major Medical Adjustment.
CO 103 Provider promotional discount (e.g., Senior citizen discount).
OA 104 Managed care withholding.
OA 105 Tax withholding.
OA 106 Patient payment option/election not in effect.
CO 107 Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.
PI 108 Payment adjusted because rent/purchase guidelines were not met.
OA 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
CO 110 Billing date predates service date.
CO 111 Not covered unless the provider accepts assignment.
PI 112 Payment adjusted as not furnished directly to the patient and/or not documented.
CO 114 Procedure/product not approved by the Food and Drug Administration.
PI 115 Payment adjusted as procedure postponed or canceled. This change effective 1/1/2008: Payment adjusted as procedure postponed, canceled, or delayed.
OA 116 Payment denied. The advance indemnification notice signed by the patient did not comply with requirements.
CO 117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
OA 118 Charges reduced for ESRD network support.
CO 119 Benefit maximum for this time period or occurrence has been reached.
OA 121 Indemnification adjustment.
OA 122 Psychiatric reduction.
CO 125 Payment adjusted due to a submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
PR 126 Deductible -- Major Medical
PR 127 Coinsurance -- Major Medical
CO 128 Newborn's services are covered in the mother's Allowance.
CR 129 Payment denied - Prior processing information appears incorrect.
OA 130 Claim submission fee.
OA 131 Claim specific negotiated discount.
OA 132 Prearranged demonstration project adjustment.
OA 133 The disposition of this claim/service is pending further review.
OA 134 Technical fees removed from charges.
CO 135 Claim denied. Interim bills cannot be processed.
OA 136 Claim adjusted based on failure to follow prior payer’s coverage rules. (Use Group Code OA).
OA 137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
CO 138 Claim/service denied. Appeal procedures not followed or time limits not met.
CO 139 Contracted funding agreement - Subscriber is employed by the provider of services.
PR 140 Patient/Insured health identification number and name do not match.
OA 141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
CR 142 Claim adjusted by the monthly Medicaid patient liability amount.
OA 143 Portion of payment deferred.
CR 144 Incentive adjustment, e.g. preferred product/service.
PI 145 Premium payment withholding
CO 146 Payment denied because the diagnosis was invalid for the date(s) of service reported.
OA 147 Provider contracted/negotiated rate expired or not on file.
OA 148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
PR 149 Lifetime benefit maximum has been reached for this service/benefit category.
PI 150 Payment adjusted because the payer deems the information submitted does not support this level of service.
PI 151 Payment adjusted because the payer deems the information submitted does not support this many services.
PI 152 Payment adjusted because the payer deems the information submitted does not support this length of service.
PI 153 Payment adjusted because the payer deems the information submitted does not support this dosage.
PI 154 Payment adjusted because the payer deems the information submitted does not support this day's supply.
OA 155 This claim is denied because the patient refused the service/procedure.
OA 156 Flexible spending account payments
CO 157 Payment denied/reduced because service/procedure was provided as a result of an act of war.
CO 158 Payment denied/reduced because the service/procedure was provided outside of the United States.
CO 159 Payment denied/reduced because the service/procedure was provided as a result of terrorism.
CO 160 Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion.
OA 161 Provider performance bonus
CO 162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
CR 163 Claim/Service adjusted because the attachment referenced on the claim was not received.
CR 164 Claim/Service adjusted because the attachment referenced on the claim was not received in a timely fashion.
CO 165 Payment denied /reduced for absence of, or exceeded referral
PR 166 These services were submitted after this payers responsibility for processing claims under this plan ended.
CO 167 This (these) diagnosis(es) is (are) not covered.
PR 168 Payment denied as Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan
PI 169 Payment adjusted because an alternate benefit has been provided
CO 170 Payment is denied when performed/billed by this type of provider.
CO 171 Payment is denied when performed/billed by this type of provider in this type of facility.
CO 172 Payment is adjusted when performed/billed by a provider of this specialty
CR 173 Payment adjusted because this service was not prescribed by a physician
CO 174 Payment denied because this service was not prescribed prior to delivery
CO 175 Payment denied because the prescription is incomplete
CO 176 Payment denied because the prescription is not current
PR 177 Payment denied because the patient has not met the required eligibility requirements
CR 178 Payment adjusted because the patient has not met the required spend down requirements.
CR 179 Payment adjusted because the patient has not met the required waiting requirements
CR 180 Payment adjusted because the patient has not met the required residency requirements
CR 181 Payment adjusted because this procedure code was invalid on the date of service
CR 182 Payment adjusted because the procedure modifier was invalid on the date of service
CO 183 The referring provider is not eligible to refer the service billed.
CO 184 The prescribing/ordering provider is not eligible to prescribe/order the service billed.
CO 185 The rendering provider is not eligible to perform the service billed.
OA 186 Payment adjusted since the level of care changed
OA 187 Health Savings account payments
CO 188 This product/procedure is only covered when used according to FDA recommendations.
OA 189 "Not otherwise classified" or "unlisted" procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service
CO 190 Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
CO 191 Claim denied because this is not a work related injury/illness and thus not the liability of the workers’ compensation carrier.
OA 192 Non standard adjustment code from paper remittance advice.
CO 193 Original payment decision is being maintained. This claim was processed properly the first time.
PI 194 Payment adjusted when anesthesia is performed by the operating physician, the assistant surgeon or the attending physician
PI 195 Payment denied/reduced due to a refund issued to an erroneous priority payer for this claim/service
PI 197 Payment adjusted for absence of precertification/authorization. This change effective 1/1/2008: Payment adjusted for absence of precertification/authorization/notification.
PI 198 Payment Adjusted for exceeding precertification/ authorization.
OA 199 Revenue code and Procedure code do not match.
PR 200 Expenses incurred during lapse in coverage
PR 201 Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC “Medicare set aside arrangement” or other agreement. (Use group code PR).
PI 202 Payment adjusted due to non-covered personal comfort or convenience services.
PI 203 Payment adjusted for discontinued or reduced service.
PR 204 This service/equipment/drug is not covered under the patient’s current benefit plan
CO 205 Pharmacy discount card processing fee
OA 206 NPI denial - missing
OA 208 NPI denial - not matched
OA 209 Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group code OA)
PI 210 Payment adjusted because pre-certification/authorization not received in a timely fashion
CO 211 National Drug Codes (NDC) not eligible for rebate, are not covered.
PI A0 Patient refund amount.
OA A1 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
CO A4 Medicare Claim PPS Capital Day Outlier Amount.
CO A5 Medicare Claim PPS Capital Cost Outlier Amount.
OA A6 Prior hospitalization or 30 day transfer requirement not met.
CO A7 Presumptive Payment Adjustment
OA A8 Claim denied; ungroupable DRG
PR B1 Non-covered visits.
CO B10 Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.
OA B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
OA B12 Services not documented in patients' medical records.
OA B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.
CO B14 Payment denied because only one visit or consultation per physician per day is covered.
OA B15 Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
CO B16 Payment adjusted because `New Patient' qualifications were not met.
OA B18 Payment adjusted because this procedure code and modifier were invalid on the date of service
OA B20 Payment adjusted because procedure/service was partially or fully furnished by another provider.
OA B22 This payment is adjusted based on the diagnosis.
CO B23 Payment denied because this provider has failed an aspect of a proficiency testing program.
CO B4 Late filing penalty.
CO B5 Payment adjusted because coverage/program guidelines were not met or were exceeded.
CO B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.
CR B8 Claim/service not covered/reduced because alternative services were available, and should have been utilized.
PR B9 Services not covered because the patient is enrolled in a Hospice.
PI W1 Workers Compensation State Fee Schedule Adjustment

Medicare Payments Reimbursement Program

Social Security / Medicare Payments Reimbursement Program

ARTICLE I -  Purpose

1.1 Some Employees of Los Alamos National Security, LLC ("LANS") who were previously employees of the University of California at Los Alamos National Laboratory ("LANL") were not required to pay Social Security/Medicare taxes on compensation from LANL, but are now required to pay Social Security/ Medicare taxes on compensation from LANS. Because of the number of years some of these employees worked for LANL, it is likely they will never be eligible for Social Security benefits. This program is designed to reimburse such Social Security/Medicare tax deductions to those LANL employees who elected TCP 1, began paying Social Security/Medicare taxes as a LANS employee upon their transition to LANS employment on June 1, 2006, and who subsequently attain age 65 without having earned entitlement to Social Security benefits.


ARTICLE II -  Program Eligibility

2.1 LANS will refund an amount equal to the Social Security/Medicare taxes withheld from the pay of any LANS employee (including a former LANS employee) who:

(a) Opted out of Social Security while employed by UC/LANL, elected TCP 1 and transitioned from UC/LANL to LANS employment effective June 1, 2006;
(b) Began paying Social Security/Medicare taxes due to such transition to LANS employment;
(c) Meets the minimum requirements to receive a retirement benefit under TCP 1;
(d) Is not eligible for Social Security benefits upon attainment of age 65, whether or not employed by LANS on such date, because he/she did not earn enough Social Security credits for Social Security benefits and provides documentation from the Social Security Administration that he/she is ineligible for Social Security benefits; and
(e) Provides annual documentation thereafter from the Social Security Administration that he/she continues to be ineligible for Social Security benefits because of the insufficient number of Social Security credits.




ARTICLE III -  Applying For Reimbursement

3.1 To receive reimbursement payments under this program, an eligible LANS employee or former employee must:

(a) Within 90 days after attaining age 65, provide LANS with an original of his/her annual Social Security Statement dated within 90 days of his/her 65th birthday indicating he/she is not eligible for Social Security benefits because of insufficient Social Security credits.


(b) Within 90 days of each birthday thereafter, provide LANS with an original of his/her Social Security Statement dated within 90 days of that birthday indicating continuing ineligibility for Social Security benefits due to insufficient Social Security credits.




ARTICLE IV -  Reimbursement Determination and Payment

4.1 If the eligible employee has timely provided the employee's latest Social Security Statement indicating ineligibility for Social Security benefits based on insufficient credits, the reimbursement for that year will be paid on the 120th day following the eligible employee's birthday (if this day does not fall on a business day, then payment will be made on the next business day) .

 4.2 The annual reimbursement amount will be equal to the total Social Security/Medicare tax withholding for the employee during active employment with LANS as shown on the employee's W-2 forms during the employee's employment with LANS, divided by the number of complete months of active employment with LANS until age 65, multiplied by 12. The first payment will be prorated based on the number of complete calendar months remaining in the calendar year after the employee's attainment of age 65. The last annual payment will be prorated based on the remaining balance due to the employee at that time. The annual reimbursement payments will not include interest on any withheld amounts.

4.3 For employees who are active employees at age 65 and continue to have Social Security/Medicare tax withholding from LANS compensation after reaching age 65, an additional reimbursement payment will be included in the annual reimbursement payment scheduled to be made in accordance with paragraphs 4.1 and 4.2 in the year following the year in which the employee reaches age 65 if all other requirements for eligibility to receive the annual reimbursement payments in Article II are met. The amount of the additional reimbursement payment for that year, shall be equal to the total Social Security/Medicare tax withheld by LANS from the employee's pay for the prior year pay periods beginning after the employee reaches age 65. In subsequent years, the amount of any additional reimbursement based on working past age 65 and having the Social Security/Medicare tax withheld from pay shall be equal to the amount of such withholding in the prior year and shall be included in the annual reimbursement payment scheduled to be made that year or if no further annual reimbursement payments are scheduled, on the date such reimbursement payment would have occurred. The additional annual reimbursement payments will not include interest on any withheld amounts.

EXAMPLE 1: The total Social Security/Medicare withholdings for an employee who is not an active employee was $8,750 dollars from June 1, 2006 until attainment of age 65 on April 30, 2009 (35 months). If the employee provides the required documentation annually, the annual amount of benefit is calculated as $8,750/35 months x 12 = $3,000 annual payment.

LANS will pay the employee the first annual reimbursement payment on August 28, 2009. A payment of $2,000 would be made to the employee (8/12 x $3,000 = $2,000);

 The next annual reimbursement payment of $3,000 will be made on August 30, 2010 (full year for 2010);

 Another $3,000 annual reimbursement payment will be made on August 29, 2011 (full year for 2011); and


 A final annual reimbursement payment of $750 will be made on August 28, 2012 (the remaining balance).


EXAMPLE 2: Same as Example 1, except the employee is still an active employee and continues to work until April 30, 2010. From May 1, 2009 through December 31, 2009, $2,000 of Social Security/Medicare taxes are withheld from his/her compensation, and between January 1, 2010 and April 30, 2010, $1,000 of Social Security/Medicare taxes are withheld from his/her compensation. If the employee meets all the eligibility requirements throughout this time, in addition to the reimbursement payments described in Example 1, additional annual reimbursement payments totaling $3,000 will be owed to the employee.

 LANS will pay the employee the first additional annual reimbursement payment on August 30, 2010 in the amount of $2,000; and

 The final payment of the additional annual reimbursement will be made on August 29, 2011 in the amount of $1,000.

Social Security / Medicare Payments Reimbursement Program

ARTICLE VI - Termination of Reimbursement Payments

6.1 All reimbursement payments will terminate in the event of any of the following:

(a) The employee has been reimbursed for the full amount of Social Security/Medicare taxes withheld by LANS during active employment with LANS.

(b) The employee fails to timely provide LANS with required documentation of ineligibility for Social Security benefits, unless such failure is due to reasonable cause (to be determined by LANS).

(c) The employee becomes eligible for Social Security benefits because he/she earns enough credits to qualify for Social Security benefits, based on his/her credits, but not because he/she becomes eligible for Social Security disability benefits, survivor benefits, or other benefits not based on his/her credits. If the employee's eligibility for the reimbursement payments terminates under this paragraph, LANS will not make any further payments that would otherwise be due under this program.


EXAMPLE 3: Same as Example 1, except the employee becomes eligible for Social Security benefits based on his/her earnings credits beginning on May 1, 2011.

 LANS will pay the first annual reimbursement payment on August 28, 2009 of $2,000;

 The next annual reimbursement payment of $3,000 will be made on August 30, 2010; and

 No reimbursement payments will be made in 2011 or thereafter.


ARTICLE VII -  Payment of Reimbursement Payments Upon Death of Employee

7.1 If an employee dies after reimbursement payments have begun, but before all reimbursement payments have been paid, any remaining reimbursement amounts will be made to the estate of such employee in one lump sum as soon as administratively possible after the death of the employee.

7.2 If an employee dies before reaching age 65 and a representative of his or her estate provides documentation from the Social Security Administration that the employee had not earned enough credits to be eligible for Social Security benefits at the time of death, reimbursement payments equal to the amount due to such employee under this program if he or she had reached age 65 will be made to the estate of such employee in one lump sum as soon as administratively possible after the death of the employee.

Indemnity Plans

The benefit of choosing an indemnity plan as your type of health insurance plan, otherwise known as a fee-for-service plan, is that it doesn't bog you down into a single network of physicians. Indemnity plan holders are given the freedom to choose/visit the doctor of their choice. In the case of indemnity plans, the remaining bill is then submitted to the insurance provider who pays the covered expenses. (Typically this consists of approx. 80% of the bill, leaving indemnity plan holders to pay the other 20%) This type of health insurance plan generally has what is called an "out-of-pocket" maximum. After this kicks in, your health plan provider pays for all covered benefits.

What you should know prior to purchase?



Although the most expensive type of health insurance policy, indemnity, or Fee-for-service insurance gives you the most flexibility and freedom to go to the doctor / medical facility / health care specialist of your choice. After receiving treatment, you must submit a claim to your insurance company (doctor or facility generally handles submissions) in order to receive reimbursement. Indemnity plans are customized so as to fit the needs of each unique policyholder, and as such, you will only be reimbursed for healthcare expenditures specified by your policy.

Medicare - Medically-necessary services & Preventive services

Services Part B Covers


There are two kinds of Part B-covered services:


Medically-necessary services — Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.


Preventive services — Health care to prevent illness or detect it at an early stage, when treatment is most likely to work best (for examples see Medicare & You Handbook ).


What You Pay for Part B Services

Costs for Part B services depend on whether you have Original Medicare or are in a Medicare health plan. For some services, there are no costs, but you may have to pay for the doctor’s visit. If the Part B deductible applies, you must pay all costs until you meet the yearly Part B deductible before Medicare begins to pay its share. Then, after your deductible is met, you typically pay 20% of the Medicare-approved amount of the service. You can save money if you choose doctors or providers who accept assignment.

Financial responsibility process

What is Financial Responsibility?

Financial responsibility is the process of managing money and other assets in a manner that is considered productive and in the best interests of the individual or family. Being proficient at the task of finance and money management involves cultivating a mindset that makes it possible to look beyond the wants of today in order to provide for the needs of tomorrow. In order to achieve a high level of financial responsibility, it is necessary to understand several basic principles.

The process of fiscal responsibility begins with understanding the difference between needs and wants. Making this distinction helps to ensure that the more important purchases are taken care of, while goods and services that are not essential to maintaining a decent quality of life are acquired after needs are met. Some examples of needs that would apply to most people include food, clothing, and shelter. Many people would also feel that earning educational credentials that are at least university level is also a need in today’s world.

Once there is a clear understanding of the difference between wants and needs, the next step in financial responsibility involves learning what to do with money left over once those basic living needs are met. Saving money should be a priority when evaluating ways to spend your surplus income. Even if no more than a small percentage of the weekly paycheck is set aside in some type of interest bearing account, that amount will grow over time and create a degree of financial security that would not be possible otherwise. Being good with money sometimes means saving a portion of available resources for emergencies or for use later in life.

Creating and sticking to a budget is basic to financial responsibility. People are never too young to begin this process. For example, a teenager who is old enough and has a part time job is in a position to make efficient use of a budget. While food and shelter may not be line items for the time being, there is a good chance that setting aside money for meals out, dates, car payments and car insurance will be considered important. By creating a budget that addresses all relevant expenditures and then prioritizing those budget items, it is easier to understand where the pay from that part time job is going and how to use that money to better effect.

Resisting impulse buying is also key to financial responsibility. This can often be difficult for even the best of money managers. There are constant visual and audio stimuli through the various forms of media to entice people to purchase items they do not need and in some cases cannot comfortably afford. Choosing to shop with a list can cut down on impulse buying to some degree. Another way to stem impulsive purchases is to set aside a fixed amount in the budget that is considered “free” money – that is, money that can be spent on any type of whim the individual desires. But once the free money is gone, there is no more impulse buying for the remainder of the budget period.

Because financial responsibility involves wise spending, the savvy money manager will learn to determine if the time is right to make a particular purchase. This often involves asking a few basic questions. Is this purchase to replace something of importance, such as a vehicle? Would it be possible to continue using the current item for a while longer and possibly be able to afford a replacement of greater quality later on? If replacement or acquisition is absolutely necessary at this time, will a product of equal quality but with a smaller price tag be acceptable? Purchases should never be made in haste, but only after weighing all the options.

No description of financial responsibility is complete without mentioning the wise use of credit. Far too many people assume that as long as it is possible to make the minimum payment on credit card balances, they are in good fiscal condition. That is not the case. Financial responsibility dictates that the less unsecured debt an individual has, the better their financial outlook happens to be. Make it a point to limit the number of credit card accounts you have, and make sure the balances are paid off each statement period or at least no more than within three periods. This will help to minimize the amount of interest paid to the credit card companies, and also provide you with a source of emergency funding in the event of an emergency.

SNF - Skilled Nursing Facility - Definition

What Is a Skilled Nursing Facility?

A skilled nursing facility is a location dedicated to the care of individuals in a residential facility, usually there on a long-term basis. These facilities specialize in the 24-hour care and observation of individuals whose needs are usually critical enough where they need constant watching, but not serious enough where hospitalization is required.

A skilled nursing facility may often be called a nursing home by some people. They are often called that because nurses, of varying degrees and certifications, take on the bulk of the patient care work. They carry out this care by working closely with a patient's team of personal doctors, following those physicians’ directions and holding consultations as necessary. Doctors also make visits, in some cases, to skilled nursing facilities to provide check-up examinations.

Traditionally, a skilled nursing facility has been used for care of the elderly, leading to the somewhat unflattering term "old folks home." However, since that time, many skilled nursing facilities have added rehabilitation to their list of services. An individual may check into a skilled nursing facility, for example, to work on physical therapy after a surgery like a hip or knee replacement.

Often, these types of surgery limit mobility and make it problematic, especially for someone who lives alone. Being at a skilled nursing facility gives these individuals a chance to have round the clock care and also receive physical therapy services in the same location.

In general, a skilled nursing facility is an option for those who can no longer carry out the functions of daily lives, either on a temporary or permanent basis. Staff at a skilled nursing facility will help the individual with a number of everyday tasks, including bathing, eating, grooming and toileting.

In the United States, time spent at a skilled nursing facility can be expensive and not always covered by health insurance. This has led many individuals to consider getting a supplement to their normal health insurance coverage that will specifically cover nursing home care. A study reported by New York Life, an American insurance company, noted the average cost of a private room at a skilled nursing facility in the United States has increase to $204 US Dollars (USD) per day. The average price of a shared room is $180 USD per day. Prices were highest in the state of Alaska, where a private room costs more than $350 USD per day.

Room arrangements in a skilled nursing facility are similar to those in hospitals. They can be either private or shared. Similarly, bathrooms can be either private or shared.

Insurance deductibel payment

What is a Deductible?

In insurance policy terms, a deductible is the amount of money which the insured party must pay before the insurance company's own coverage plan begins. In practical terms, insurance companies include a deductible in their policies to avoid paying out benefits on relatively small claims. A typical auto insurance policy, for example, may carry a $500 deductible. If the owner of that car accidentally hits another car while parking and both drivers agree the damage is minimal, he or she would pay the $500 repair bill out of his or her own pocket. Insurance companies would not encourage a claim for such minor damages.

However, this payment of $500 means that the next accident claim would be covered by the insurance company. The car owner is said to have 'met the deductible' and is now eligible for complete protection. The same holds true for medical insurance. Patients who visit the emergency room for a minor injury or procedure would have to pay out of pocket until they have reached the level of the deductible. If their medical expenses on a visit to the hospital would exceed the deductible, then the insurance company would pay the total charges minus the deductible. In either scenario, the policy holder is almost always held responsible for a small portion of their claims.

The amount of a deductible is almost always proportional to the amount of the premiums (regular payments) charged by the insurers. In order to have a lower deductible, even as low as $0, the policy holder would have to agree to higher premiums. For those who want lower premium payments, they must agree to a higher deductible. There are pluses and minuses to either option- one expensive accident or medical procedure could bring on a very high deductible payment, or a lifetime of good health and few automotive claims could make higher premiums a relative waste of money. Then again, having total coverage with little to no deductible can be a very comforting thought during a crisis, or not paying too much for unneeded coverage can help keep household finances manageable.

A deductible of some kind should be expected with any medical or automotive insurance policy. When shopping for affordable coverage, be sure to ask specific questions about the deductible and other obligations left to the policy holder. An exceptionally low premium rate may signal an equally exceptional high deductible amount. Try to find a balance between affordable premiums and a fair deductible when buying insurance.

What is Rehabilitation?

As related to matters of physical and emotional well-being, rehabilitation refers to any process that seeks to restore the patient to a previous level of health. Different types or expressions of the rehabilitative process will focus on the task of restoring at least some function to a damaged body part or utilizing the process of education to equip the individual to compensate for damage that cannot be repaired. At its core, rehabilitation has the goal of assisting individuals to achieve the highest quality of life and health as possible within their circumstances.

Physical rehabilitation is a common form of this restoring process. Often utilized after major surgery, an accident, or any event that robs the individual of mobility or function, this form of rehab pairs the patient with trained personnel who help him to recover as much of his former physical prowess as possible. In some cases, the physical therapy used as part of the process is aimed at rebuilding the strength of limbs that may have been damaged in an accident, but are now healed and in need of physical exercise. At other times, the physical rehab may be focused on helping people who have lost a limb learn how to function effectively by expanding their use of the remaining limbs.

Addressing emotional issues is often part of the rehabilitation process. This is especially true in situations where physical damage was accompanied or followed by emotional trauma. In situations of this nature, the rehab process often involves counseling with a qualified therapist as well as physical retraining. The patient may engage in therapy on a one-on-one basis with the therapist, or be part of a group therapy arrangement that allows him or her to interact with other people facing similar challenges.

Drug rehabilitation is a form of retraining that also is likely to involve both physical and emotional counseling as part of the rehab process. Physical factors can involve helping the addict to deal with physical cravings, while counseling is helpful in weakening the emotional bonds that tie the addict to his or her drug habit. Drug rehab may take place in a rehabilitation center, especially if there are other health issues that must be addressed during the rehab process. However, many people are able to overcome addiction and become fully rehabilitated through regular participation with substance abuse counseling groups or by spending time in a halfway house.

It is not unusual for a rehabilitation center to deal with several different types of physical and emotional issues. The center may include facilities that provide supervised exercise sessions to help people recover physical strength lost during an extended illness, as well as counselors and other support personnel to aid in the rehabilitation of the mind. Often, centers of this type actively measure the progress of each patient, making it a point to provide an atmosphere that is welcoming as well as encouraging.

MEDICARE FRAUD AND ABUSE

As the CMS Part B Contractor for Maine, Massachusetts, New Hampshire, and Vermont, NHIC
fully supports the CMS initiative for program safeguards and shares the following information
for your use:

Fraud is the intentional deception or misrepresentation that the individual knows to be false, or
does not believe to be true and makes, knowing that the deception could result in some
unauthorized benefit to himself/herself or some other person. The most frequent line of fraud
arises from a false statement or misrepresentation made, or caused to be made, that is material to
entitlement or payment under the Medicare program. Attempts to defraud the Medicare
program may take a variety of forms. Some examples include:
• Billing for services or supplies that were not provided;
• Misrepresenting services rendered or the diagnosis for the patient to justify the services or
equipment furnished;
• Altering a claim form to obtain a higher amount paid;
• Soliciting, offering, or receiving a kickback, bribe, or rebate;
• Completing Certificates of Medical Necessity (CMNs) for patients not personally and
professionally known by the provider; and
• Use of another person’s Medicare card to obtain medical care.

Abuse describes incidents or practices of providers that are inconsistent with accepted sound
medical practices, directly or indirectly resulting in unnecessary costs to the program, improper
payment for services that fail to meet professionally recognized standards of care, or services that
are medically unnecessary. Abuse takes such forms as, but is not limited to:

• Unbundled charges;
• Excessive charges;
• Medically unnecessary services; and
• Improper billing practices.

Although these practices may initially be considered as abuse, under certain circumstances they
may be considered fraudulent. Any allegations of potential fraud or abuse should be referred to
the Benefits Integrity Safeguard Contractor.

History of Medicare insurance

What is Medicare?

In this era of rapidly rising medical, pharmaceutical and insurance costs, the American people and Congress are talking a lot about Medicare. Medicare is the federally-funded medical plan for Americans age 65 and over that covers medical expenses such as doctor's visits, hospital stays, drugs and other treatment. The need for a medical program for senior citizens became evident in the 1950s, but it was not until 1965 that Congress passed the laws that established Medicare. The law was amended in 1972 to include people with disabilities and end-stage renal disease.

with many government programs, wading through the Medicare jungle can be confusing at best. Even insurance agents may not know all the ins and outs of dealing with Medicare, what it will cover and what it will not, or which doctors accept Medicare and which won't. It's a true labyrinth.

Essentially, all Americans are eligible for Medicare when they turn 65. There is an initial enrollment period for seven months after one's 65th birthday, when one can enroll in Medicare for free. After the enrollment period, someone who decides he wants Medicare may be subject to enrollment fees and penalties. Special enrollment periods may apply, but these are also complicated to navigate. Then, the senior citizen must decide whether to enroll in Medicare Part A only, which offers basic Medicare coverage, or also in Part B, which offers supplemental coverage. Some seniors who are covered by their company's group health insurance, or their spouse's, may decline to enroll at all, or may just decide to enroll in Part A since it is cheaper.

Some Medicare coverage is administered by HMOs, which means a private company is paid by the federal government to administer Medicare. The debate over HMOs has raged for several years. Some seniors may receive better care under an HMO, while for others, the benefits may not be as good as a federally-managed plan. It all depends on the HMO and the state where the senior lives. Each state has a different way of dealing with Medicare.

Medicare reform issues have plagued Congress for several years, and a reform bill with a prescription drug benefit was passed in 2003. Because of the changing needs of senior citizens and rising medical costs, this is an issue that Congress will probably continue to wrestle with for many more years. It is difficult to create a "one-plan-fits-all" system.

A senior citizen picking his way through the Medicare jungle will probably need help. This may come in the form of an educated insurance agent or through classes that are available in many communities. There are also numerous resources on the Internet to help a senior citizen find her way. Medicare is complicated — with many exceptions, provisions, rules, limitations, and so forth — making it seemingly impossible to unravel. The wise senior citizen will get assistance long before the time comes to enroll in Medicare.

What Are the Different Types of Renal Disease?

Renal disease is any type of disease that causes the kidneys to fail. There are several different types of renal disease.

Kidney stones are the most common form of renal disease. A kidney stone is a small, hardened material that forms in the kidney. This may cause blood in the urine and pain in the back and stomach. One method of treating kidney stones is to let the stone eventually pass through the urine. The kidneys can also have simple benign cysts, composed of small fluid filled sacs. Eventually, the cysts may dissolve and usually do not require treatment.

Hematuria, also known as blood in the urine, is a different renal problem. Blood in the urine is usually harmless and caused by urinary tract infections. Doctors normally prescribe antibiotics to clear up this infection.

One harmful type of kidney condition is polycystic kidney disease. This genetic disease causes multiple cysts to grow in the kidneys. Cysts can cause pain in the back, high blood pressure, and urinary issues. The kidneys may become damaged and not work.

When a person’s kidneys suddenly stop working, he or she will go into acute renal failure. This is caused by injury to the kidneys, medications and illness. Acute renal disease can cause harm to other areas of the body. Individuals with acute renal failure will need dialysis to filter out impurities.

When dialysis is not effective, the kidneys will cease functioning. The damage that can occur is permanent. High blood pressure, diabetes or injury to the kidneys can cause end stage renal failure. A person with this condition will most likely need a kidney transplant.

A kidney transplant involves surgically removing the diseased kidney and urethra from the patient. The patient will then get a healthy kidney and urethra from a donor. The recipient will need to take medications to make sure the body does not reject the new organs.

Persons in danger of developing renal conditions are those with diabetes, high blood pressure, or heart disease. Family members of someone who has kidney disease may also have a high risk. Elderly people have a greater chance of getting a kidney disease since age is also a factor.

Doctors can test blood to determine if any renal disease is present. The blood will have specific levels of protein and creatine that confirm a kidney condition. The physician can discuss the results with the patient and go over options for treatment.

Determine - Pay scale

What is a Pay Scale?

A pay scale is a document or table designed to determine how much an employee will earn in his or her job. Many companies have a pay scale set up before hiring new employees, which they show to prospective employees before hiring them. In this way, the job seeker can get a good idea of how much he or she can expect to earn while working for the company or business.

Not every company uses a pay scale to determine employee wages. Some companies seem to arbitrarily decide how much pay they will give an employee to start working for the company. Subsequent raises are similarly determined. Sometimes, a company without a pay scale will determine the subsequent increases in pay based on job performance or the overall performance of the company in the past year.

Similarly, some companies do not have a formal pay scale that is shared with employees, but they do have a loosely created pay scale to help them determine the amount of money they will offer to new employees. This informal pay scale may also be used by the company to determine how much of a pay increase will be offered to the employee.

Typically, a unionized company will utilize a pay scale. Often, a pay scale is presented in a table format. For careers requiring special education or training, the pay scale will generally have years of experience on the side and the amount of education or training completed on the top. The employee can then find the point where the these two factors meet in order to determine the amount of pay he or she will receive for the year. If the job does not require special education, the chart will just show the salary for a specific number of years of experience.

Union representatives meet with the company to determine the salaries presented on the pay scale. The pay scale itself is a part of the contract that the company and the union develop. The idea behind a pay scale is to ensure all employees are treated fairly and receive equal pay for equal experience and education. In this way, favoritism in the form of increased pay is eliminated. Although the pay scale is most often associated with unionized companies and businesses, companies without a union sometimes utilize a pay scale as well.

What is Hospital Medicare Reimbursement?

Hospital Medicare reimbursement refers to the amount of money the US Medicare program pays to hospitals. Determination of what is paid is based on what service the hospital is performing, and this usually doesn’t take location of the hospital into account. People in Topeka or New York City who have the same type of heart surgery will have their Medicare program pay the same rates. Medicare determines what it feels is reasonable payment for a particular service rendered and pays accordingly.


Since 1997, there have been some changes in the way that hospital Medicare reimbursement works. In many cases, Medicare will not pay extra if they determine that a condition develops in the hospital that was due to either poor care or human error. In other words, many preventable conditions like infections or bedsores that cause a patient to stay longer don’t result in extra reimbursement for the hospital. Some are in favor of this system, and others claim that it discourages hospitals from accepting certain patients, especially medically fragile ones.

There are a number of hospitals that contend that hospital Medicare reimbursement rates are not adequate. Very little of actual cost may be covered, and hospitals that are required to take Medicare, like many state run hospitals, may bear the brunt of attempting to operate on extremely low reimbursement rates. This might be made up in part by the amounts charged to non-Medicare patients, and especially to those who don’t have any form of insurance. It can be a vicious cycle too, because low funding can translate to under staffing, lower pay for workers, and poorer quality of workers, which in turn may lead to more human error or neglect of patients and less money paid for people’s longer hospital stays.

One aspect of this equation though is determination of “actual cost.” It’s fairly easy to figure out standard cost, but true actual cost may be a different matter. Hospitals contract with insurers at lots of different reimbursement rates, and these varying pay scales for services don’t say much about real cost. Hospital Medicare reimbursement certainly constructs analysis of costs at the low end of the pay scale, but there are also private insurers that don’t pay much more for services.


Another way of looking at hospital Medicare reimbursement is by looking at Medicare Part A, which determines hospital coverage for each patient and each patient’s financial responsibility. Under this part of Medicare, a patient has to pay a certain amount for hospital care, and this includes a deductible over $1000 US Dollars (USD) and $100 USD per day if hospitalization is at a skilled nursing facility. One of the reasons people often purchase supplemental insurance through Medicare is due to concern over needing to pay these fees.

What are Medicare Reimbursement Rates?

Medicare reimbursement rates are the rates paid to doctors for performing a certain procedure. For example, those who go to the doctor for a regular checkup, and are on Medicare, will be covered by a certain amount under the policy. That is the payment the doctor can expect. While the system is relatively straightforward and simple, there is also some controversy associated with Medicare reimbursement rates. Some doctors feel that the rates fail to meet their expenses.

All doctors have the opportunity to decide whether they want to participate in the Medicare program. Even doctors who do not officially list themselves as Medicare providers may be able to see patients and submit claims for them. If this happens, the Medicare reimbursement rates that doctor receives will be somewhat less than those a participating doctor receives. Therefore, doctors who decide to opt out of the system normally will not see Medicare patients at all.

In the past, the Medicare reimbursement rate was dependent on a complex formula that included the cost of living in the local area. A doctor in a rural state with a lower cost of living and, it is assumed, lower expenditures, would not be paid the same amount as a doctor in a metropolitan area, even if the family practice was similar. That led to many rural doctors protesting the Medicare reimbursement rates, saying that no matter where they lived they still had significant expenses, including student loans, that were on par with their big city counterparts. Further, the U.S. government realized its policy was discouraging doctors from setting up practices in under-served areas. Thus, there is now a more uniform payment distribution of Medicare reimbursement rates.

Other things may affect the rates as well. A hospital's Medicare reimbursement rate will generally be higher than that of a doctor's office. This is because the expenses of a hospital to perform the same procedure are generally greater than for a doctor in private practice with the same capability.

Those health care providers who will accept Medicare patients have no choice, but to accept Medicare reimbursement rates for any procedure they offer. They cannot pick and choose. Further, they cannot charge the patient additional co-pays to make up for what a private insurance carrier might be willing to pay for the same procedure. While these may be considered disadvantages, the benefit for the doctor comes in having access to a greater number of patients. Many of these patients will require increasing numbers of visits to the doctor as they age, thus providing a steady stream of income for the doctor.

What is a Reimbursement Plan?

A reimbursement plan is a structured strategy for repaying individuals who have incurred expenses on behalf of another entity. The most common example of this type of plan has to do with covering expenses incurred by employees as they carry out their job responsibilities. Plans of this type make it possible to ensure the employee is reimbursed in a timely manner, while also aiding the employer in keeping accurate records regarding the entire cost associated with the performance of a given task.

Reimbursement plans can be structured as accountable and non-accountable. An accountable plan calls for the employee to submit receipts for the expenses that qualify for reimbursement. A non-accountable reimbursement plan covers expenses where no receipt is required, although the employee does have to declare the expense in writing before he or she is reimbursed. For example, an employee who takes clients out to dinner will need to present the receipt for the meal in order to be compensated for the expenses. At the same time, if the employee uses his or her private vehicle in the course of completing tasks on behalf of the employer, he or she submits the total amount of mileage used, usually on an expense voucher or claim form. The employer determines the amount of reimbursement issued, based on current regulations and practices that apply.

In terms of tax deductions, an employee who participates in a reimbursement plan is normally not allowed to claim the compensated expenses as deductions on their personal income tax returns. The employer can claim the expenses that were reimbursed as deductions, subject to the provisions contained in the tax laws currently in place in the jurisdiction where the company is located. In some countries, the employee may have to declare certain forms of reimbursement as income, especially in situations such as mileage where there is no specifically documented out-of-pocket expense.

A wide range of expenses may be covered in a reimbursement plan. Employees who travel as part of their work are often allowed to submit expenses such as airfare, lodgings, car rentals, and meals for reimbursement. An employee may also be compensated for expenses incurred while working on a special project for the company, such as serving as the representative of the business at a local event. Often, government regulations define the scope of what is considered a reimbursable expense, and what procedures must be followed in order for the employer to claim the reimbursed expense when filing tax returns. These regulations typically shape the internal policies and procedures used by a business to structure and carry out the reimbursement plan.

Medicare reimbursement basic concept

What Is Medicare Reimbursement?

Medicare reimbursement is the name applied to the payments that physicians and hospitals receive for services rendered to patients who are covered under the Medicare program. The money will go directly to the billing provider, but Medicare insurance does not pay the full amount. Due to the rates set by Medicare, the Medicare reimbursement program can often be very contentious and a hotbed for political exploitation.

 Those physicians who want to participate in the Medicare reimbursement program have a couple of options. One of those options is to look at the fee schedule and accept assignment. Any participating physician that accepts assignment must accept the rate Medicare sets as the price for that service. Medicare will take that amount and pay 80 percent of it. The patient will be responsible for the rest.

Once a physician becomes a participating physician in the Medicare reimbursement program, all fee schedules for the services offered must be accepted. However, this does not mean the physician will be required to accept all Medicare patients. Once a physician becomes a participating physician, he or she is usually locked into that role for a year.

Some physicians do not feel they can adequately make a profit based on the fee schedule provided through the Medicare reimbursement policy and therefore may opt out of the program. These non-participating physicians can then accept Medicare fee schedules on a case-by-case basis. However, they can then only charge 95 percent of that fee schedule.

The best way to illustrate what this means for the patient and doctor is to use an example. If a procedure performed has an acceptable fee of $200 US Dollars (USD) to Medicare, the Medicare coverage will pay 80 percent of that, or $160 USD. The patient is responsible for the additional $40 USD. However, if the physician is a non-participant performing this procedure for Medicare, he or she can only charge 95 percent of that, or $190 USD. Medicare will then pay $152 USD, leaving the remaining $38 up to the patient or secondary insurance coverage. The physician also has the option of not putting in a Medicare reimbursement claim, if he or she is a non-participating physician.

Some physicians claim that the Medicare reimbursement fee schedules are inadequate and they cannot make a profit or even break even if they were to use them. That is one reason many may opt not to participate. In other cases, they may simply limit the number of Medicare patients they see.

 

Medicare payment for CPT 77051, 77052 & 77055

MEDICARE REIMBURSEMENT FOR MAMMOGRAPHY SERVICES

Table 1: 2009 Medicare Reimbursement for Mammography Procedures
(Reflects National Rates, Unadjusted For Locality)

Technology :  Computer-Aided Detection (CAD)


CPT/HCPCS Code : CPT 77051 Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to
code for primary procedure) [Use 77051 in conjunction with 77055, 77056]

Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:

Technical                                                        $9.02
Professional                                                   $3.25
Global                                                             $12.26

CPT/HCPCS Code :CPT 77052 Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to
code for primary procedure) [Use 77052 in conjunction with 77057]


Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:


Technical                                                        $9.02
Professional                                                   $3.25
Global                                                             $12.26





Technology : Plain Film

CPT/HCPCS Code :  CPT 77055 Mammography; unilateral


Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:


Technical                                                       $49.05
Professional                                                  $35.71
Total                                                               $84.76


CPT/HCPCS Code : CPT 77056 Mammography; bilateral (Use 77055, 77056 in conjunction with 77051 for CAD applied to diagnostic mammogram)


Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:


Technical                                                       $63.12

Professional                                                  $44.36
Total                                                              $107.48


CPT/HCPCS Code :  CPT 77057 Screening mammography, bilateral (2-view film study of each breast) (Use 77057 in conjunction with 77052 for CAD applied to a screening mammogram


Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:


Technical                                                       $45.80

Professional                                                  $35.71
Total                                                               $81.51




Technology : Digital

CPT/HCPCS Code :  HCPCS G0202 Screening mammography, producing direct digital image, bilateral, all views


Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:


Technical                                                       $94.86

Professional                                                  $34.98
Total                                                               $129.84


CPT/HCPCS Code :  HCPCS G0204 Diagnostic mammography, producing direct digital image, bilateral, all views

Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:


Technical                                                      $109.28

Professional                                                 $43.28
Total                                                             $152.56


CPT/HCPCS Code :  HCPCS G0206 Diagnostic mammography, producing direct digital image, unilateral, all views

Reimbursement Component :                     Hospital Outpatient/IDTF/Physician Office:


Technical                                                     $86.20

Professional                                                $34.98
Total                                                            $121.18


* Technical- is the facility payment
**Professional- is the physician payment

Coverage

As established in legislation, Medicare provides conditions of coverage for both screening and diagnostic mammography services. Coverage guidelines address the types of services covered; requirements for providers of service; patient’s eligibility; and frequency limitations. To review information on Medicare’s coverage conditions for mammography services, refer to Medicare’s National Coverage Determination, Mammograms, in the Internet Manual for Medicare National Coverage Determinations at http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf

(scroll to section 220.4), as well as information located in the Internet Manual for MedicareBenefit Policy at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf (scroll to section 280.3).