This video will review Medicare at its most basic level. Medicare has four parts. Part A is commonly referred to as hospital insurance. It is paid for by payroll taxes, requires no additional premium, and covers services performed in a facility such as a hospital, skilled nursing facility, or by a home health agency. Medicare Part B is the part that covers physicians and other outpatient services. Part B is voluntary and does require an additional monthly premium to enroll. This video will focus mostly on Part B. Medicare Part C is also known as Medicare Advantage. It is a voluntary program where private payers manage Medicare benefits. The plans offered must cover what Medicare does, but often offer additional services as well. A premium is required to enroll, and some plans require higher premiums than Medicare Part B. Finally, Medicare Part D manages prescription drug coverage. Medicare Part B is paid on a fee-for-service basis, or a payment is made for each service provided. The Medicare Physician Fee Schedule, which sets the payment rates, is published yearly. The proposed rule is released in the summer and includes information on all of the potential policy changes, as well as the yearly conversion factor, which is used to determine the payment rate. CMS accepts comments on the rule for 60 days. After reviewing public comments, CMS issues the final rule in November of each year. When determining fee schedule rates from year to year, it is important to know that CMS is bound by budget neutrality. That means when a new CPT code is introduced or codes are revalued, that additional value has to be taken from other codes. There will be no increases to the fee schedule until 2026, and even then, they will only be at 0.25%. This is why there have been so many fee schedule cuts in recent years. The Center for Medicare and Medicaid Services, or CMS, is in charge of the management of the Medicare program, but they contract out the claims processing operations to private insurers. There are six Medicare Administrative Contractors, or MACs, each responsible for a different region of the country. The MACs are responsible for all claims processing and payment. MACs can also make their own policies. Refer to your MAC's website for the most up-to-date information. Here is the current map of MAC jurisdictions. To become a Medicare provider, you must enroll. The easiest way to enroll is by using the online enrollment system, PECOS. Enrollment is required for all types of Medicare participation. To be a participating provider in the Medicare program, you must agree to accept assignment. That means you accept the Medicare fee schedule amount as payment in full and will file a claim for the beneficiary. In return, you will be paid at the full fee schedule rate and receive payments directly from Medicare. Another option is to be a non-participating provider. Being non-PAR gives you the right to bill the patient up to 115% of the limit in charge. However, you must collect the entire balance from the patient because Medicare will send the payment directly to the patient. In addition, if you decide to accept assignment on a claim to receive direct payment, Medicare will only reimburse 95% of the physician fee schedule rate. Another option is to opt out of Medicare. This is the only option that allows the provider to bill the patient in full for services rendered. The provider must sign an affidavit on the PECOS website and sign a contract with the patient to provide services on a cash basis. The patient and the provider cannot seek reimbursement from Medicare. Opt-out lasts for two years. The only time a PAR or non-PAR provider can bill the patient for services is when the services are not covered by the Medicare program. To do so, they must give the patient an advanced beneficiary notice, or ABN, prior to the service being rendered. A copy of the form can be found on the CMS website and looks like this. The notice must be specific to the service being rendered and clearly state why Medicare will not cover the service. A blanket ABN is not acceptable. The patient then has a choice to refuse the service or pay for it. The option should be explained, but the provider cannot influence the patient's decision. The patient's choice must be honored. Medicare Part B payment is based on medical necessity. No prior authorizations are required, but claims may be reviewed after submission. Specific coverage guidelines are issued nationally through national coverage determinations and locally by the MACs through local coverage determinations. National coverage determinations apply to all MACs. These national payment policies may be reviewed at the CMS website. Local coverage determinations apply only to one specific MAC or jurisdiction. Local coverage articles provide additional information about the policy, such as what CPT and diagnosis codes are included. CMS has a database where you can search both NCDs and LCDs. Another source of Medicare payment policy is the Medicare Benefit Policy Manual, which can also be accessed from the CMS website. The Medicare Claims Processing Manual provides more specific details about claim submission and payment and can also be found on the CMS website. It is also a good idea to stay on top of MAC policy changes by subscribing to bulletins and newsletters issued by your MAC. The MAC websites are also a valuable source of information. Another CMS policy is the National Correct Coding Initiative. NCCI was implemented to prevent improper billing and provides edits for what procedures cannot be billed together and how many units can be billed per day. Edits are updated quarterly. They can be found on the CMS website. The procedure-to-procedure edits provide a list of code pairs and indicate whether they can never be billed together or if, in certain situations, a modifier 59 may be appropriate. It is important to remember that modifier 59 being allowed does not automatically mean that two procedures should be payable together. Using modifier 59 is only appropriate when the second procedure is performed at a separate anatomical location during a separate encounter or when a diagnostic procedure leads to a therapeutic procedure on the same date of service. MUE edits indicate the number of times a code can be billed in one day. Medicare Part C, or Medicare Advantage, is the other program that pays for physician services. Beneficiaries choose to enroll in a plan run by a private insurer. Be aware that these plans can have the same requirements as private insurance, such as prior authorizations and referrals, so be sure to check the plan's policies. Medicare Advantage plans must offer the same benefits as Medicare but can include additional benefits as well. Medicare Advantage plans pay Medicare fee schedule rates. So, when you decide to see a Medicare patient, here are a few key points to remember. First, choose your participation status. Then, remember Part B is voluntary, so be sure that your patient has enrolled in Part B coverage. If your patient is enrolled in a Medicare Advantage plan, be sure to confirm policy requirements, including if you have to be a contracted provider with that payer to render services. And do not bill a Medicare patient for the entire service unless you opt out or the patient has completed and may be in.

Medicare

Medicare overview

Medicare parts

Medicare Part B

Center for Medicare and Medicaid Services (CMS)