Medicare

The Medicare program provides healthcare coverage for people 65 or older, people under the age of 65 with certain disabilities, and people of all ages with End-Stage Renal Disease. Medicare has three components: Part A for hospital coverage, Part B for physician services, and Part D for prescription coverage. Individuals may opt out of Medicare and enroll in a Medicare Advantage Plan, referred to as Part C. For more information on Part C visit our Medicare Advantage web page.

QMB/Dual Eligible Demonstration Project

Advanced Beneficiary Notice (ABN) 

In order to obtain payment from Medicare patients for services that a physician feels may be denied, an ABN is required to serve as notification to patients that they will bear financial responsibility for the service or item. The ABN must be furnished in advance of providing the items or services to establish that a physician informed the patient of possible non-coverage and therefore shifts financial liability to the patient in the event of a denial. Some examples of when an ABN is required is when services/items:

• exceed frequency limitations
• are considered experimental and investigational
• are not indicated for the diagnosis, treatment of illness, injury, or to improve function
• are not reasonable or necessary under program standards
• are a covered preventive service but provided outside the statutory timeframes 

The ABN is only to be used for traditional Medicare patients and is not valid for Medicare Advantage Plans (Part C) or Medicare Drug Plans (Part D). However, although the ABN is specific to Medicare, many payors utilize similar forms with like rules. The ABN is not needed to notify patients before an item or service is provided when it isn’t a Medicare benefit or never covered. However, as a courtesy, a voluntary ABN may be given to inform the patient about their financial liability. Issuing the notice voluntarily doesn’t affect financial liability, and the patient isn’t required to check an option box or sign and date the notice. 

Medicare pays close attention to the correct use of the ABN form. Incorrect use exposes a practice to costly, time-consuming audits which can lead to recoupments and penalties and even jeopardize Medicare participation. More information can be found in the MLN ABN Booklet.

Other Topics:

• Alternative Payment Programs/ACOs - Medicare has several alternative payment programs and opportunities for physicians that focus on quality, cost, and pay for performance. 

• Chronic Care Management - This section provides information on how to bill for the Chronic Care Management codes, patient eligibility how to get started and more.

• CMS Proposed and Final Rules

• Enrollment, Provider Record Changes and Opt-out Procedures

• Part B Immunization Billing, Seasonal Influenza Vaccines Pricing - These resources provide guidance on immunization billing and seasonal payment rates. 

• Physician Directory - The Medicare Participation Physicians/Suppliers Directory (MEDPARD) contains the names, addresses, telephone numbers and specialties of Medicare Participating physicians and suppliers.

• Preventive Services Chart - Guidance on properly furnishing and billing Medicare preventive services with information by service.

• Medicare Reimbursement - The Medicare Part B Physician's Fee Schedule is available for download on the Novitas website.
       - Novitas online Fee Schedule Look-up
       - Medicare deductible and coinsurance information
     - Patient billing protections - Medicare Interactive, KFF 

• Medicare Secondary Payor guide - Guidance on determining when Medicare is primary or secondary.

• Merit-based Incentive Payment System (MIPS) - MIPS is a quality reporting program that consolidates the previous quality reporting programs and began its first performance year in 2017.

• Novitas online appeals and appeals status - Appeals can be submitted online through Novitasphere. The appeals inquiry tool allows you to determine the status of appeals and reconsiderations. Go to the Novitas website. Click on Jurisdiction H. On the left-hand side menu, hover over Appeals, then select Status of My Appeal.

• Quality Payment Program - The Medicare Access and CHIP Reauthorization Act of 2015 repealed the Sustainable Growth Rate (SGR) and replaced it with the Medicare Quality Payment Program (QPP).
  
  
• Recoupments - This MLN discussed the limitations on recoupments when such has been appealed.

• Revalidation

• Where to File Complaints - Complaints may be mailed, faxed, or emailed. Emailed complaints must be sent securely via encryption or password protection. Follow the instructions on how to file a complaint and how to encrypt or password protect an emailed complaint on the Where to File Complaints guide.