Medicare reimbursement basic questions - provider accept assignment

When I see my doctor, must I pay first and then get Medicare to reimburse me?

It depends on your doctor and on whether your doctor accepts assignment.

If your doctor accepts assignment:
 
He or she can only ask you to pay the 20 percent coinsurance (45 percent for mental health services) up front (and your Part B deductible if you have not yet reached it—$155 in 2010). Your doctor files the claims, and Medicare pays the doctor directly.

If your doctor does NOT accept assignment:
 
Your doctor may ask you to pay the full amount for services in advance and charge you up to 15 percent more than Medicare’s approved amount under federal law. Some states have stricter limits on what your doctor can charge you. See the MI Extra to find out what percent of the Medicare-approved amount a non-participating provider may charge you in your state in addition to the Medicare coinsurance.

Medicare will reimburse you directly for its part of the bill (80 percent of Medicare's approved amount for most medical services; 55 percent for mental health services).

Medicare premiums and coinsurance rates for 2010

Medicare premiums and coinsurance rates for 2010

The following is a listing of the Medicare premium, deductible, and coinsurance rates that will be in effect in 2010:

Medicare Premiums for 2010:

Part A: (Hospital Insurance) Premium

    *       Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.
    *       The Part A premium is $254.00 per month for people having 30-39 quarters of Medicare-covered employment.
    *       The Part A premium is $461.00 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.

Part B: (Medical Insurance) Premium

Most beneficiaries will continue to pay the same $96.40 premium amount in 2010.  Beneficiaries who currently have the Social Security Administration (SSA) withhold their Part B premium and have incomes of $85,000 or less (or $170,000 or less for joint filers) will not have an increase in their Part B premium in 2010.  For additional details, see our FAQ titled: "Will my Medicare Part B premium increase in 2010?"

For all others, the standard Medicare Part B monthly premium will be $110.50 in 2010, which is a 15% increase over the 2009 premium.  The Medicare Part B premium is increasing in 2010 due to possible increases in Part B costs.  If your income is above $85,000 (single) or $170,000 (married couple), then your Medicare Part B premium may be higher than $110.50 per month.  For additional details, see our FAQ titled: "2010 Part B Premium Amounts for Persons with Higher Income Levels".

Medicare Deductible and Coinsurance Amounts for 2010:

Part A: (pays for inpatient hospital, skilled nursing facility, and some home health care) For each benefit period Medicare pays all covered costs except the Medicare Part A deductible (2010 = $1,100) during the first 60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days.

For each benefit period you pay:

    *       A total of $1,100 for a hospital stay of 1-60 days.
    *       $275 per day for days 61-90 of a hospital stay.
    *       $550 per day for days 91-150 of a hospital stay (Lifetime Reserve Days).
  
    *      All costs for each day beyond 150 days

Skilled Nursing Facility Coinsurance

    *       $137.50 per day for days 21 through 100 each benefit period.

Part B: (covers Medicare eligible physician services, outpatient hospital services, certain home health services, durable medical equipment)

    *       $155.00 per year. (Note: You pay 20% of the Medicare-approved amount for services after you meet the $155.00 deductible.)


Related Links :

• Medicare reimbursement rates increase

• Medicare reimbursement rates for GI

• What is hospital medicare reimbursement

• How much i need to pay for medicare

Medicare Reimbursement Rates Increase For Advanced Biologically-Based Fistula Treatment

Medicare Reimbursement Rates Increase For Advanced Biologically-Based Fistula Treatment

Hospitals nationwide will receive six percent higher reimbursement payments for outpatient repair of anal fistulas using Cook Medical's Biodesign Fistula Plug, a device designed specifically to treat this painful and embarrassing disorder of the lower GI tract. According to new Medicare payment schedules effective January 1st, hospital outpatient surgery departments will receive approximately $2,200 per procedure, while freestanding ambulatory surgery centers will be paid about $1,300 on average1. The new fee levels come at an opportune time, as fistulas continue to affect tens of thousands of patients each year in North America alone.

The Centers for Medicare and Medicaid Services (CMS) regularly review charge data from health care providers to determine future facility reimbursement rates. New Medicare fee schedules, published annually, reflect CMS goal of establishing appropriate payment rates without creating disincentives that could deprive patients of effective treatment. The actual amount of facility reimbursement depends on a number of factors, including the provider and/or site of service (whether a physician, hospital, or ambulatory service, whether inpatient or outpatient) and the facilities' geographic location. Unlike Medicare, commercial insurance plans do not have a consistent national payment methodology, and fee arrangements between these insurers and health care providers vary considerably.

Since Cook introduced the Biodesign Fistula Plug in 2005, health care providers have increasingly recognized the strong performance of biologic grafts for fistula repair. A fistula is an abnormal channel that develops between body organs or an organ and the skin, often in the intestinal tract. Anal fistulas can develop because of mechanical stress caused by Crohn's disease, colitis, diverticulitis and other inflammatory bowel diseases.2 They leak fluid, interfere with bowel movements and cause discomfort during sitting and moving. Many can be repaired with a simple procedure called a fistulotomy, but approximately 30 percent of anal fistulas are considered complex and require alternative treatments less likely to prevent anal incontinence.

The Biodesign Fistula Plug is the first device designed and FDA cleared specifically for closing anal fistulas. Unlike other forms of treatment, the Biodesign Fistula Plug does not have a risk of sphincter muscle damage, a potential complication of fistulotomy that can cause incontinence. To further optimize procedural outcomes, Cook recently introduced the Biodesign Fistula Plug Set, a collection of accessory tools designed to help physicians achieve best outcomes in use of the Biodesign Fistula Plug. Available now, the Biodesign Fistula Plug Set includes the Biodesign Fistula Plug itself, brush, irrigation catheters, syringe and sutures.


Related Links :

• Medicare reimbursement rates for gi

• What is hospital medicare reimbursement

• What are medicare reimbursement rates

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Medicare reimbursement rates for GI hospital

GI - Hospital Fee Schedule for  FL

POS	CPT	Description	MCR Allowed	Coins 20%	Comment
Hospital	43200	ESPHGSC RGD/FLX DX +-COLLJ SPEC BR/WA SPX	$154.12	$30.82
Hospital	43202	ESPHGSC RGD/FLX W/BX 1/MLT	$201.91	$40.38
Hospital	43235	UPPER STOMACH-INTESTINE SCOPE FOR DIAGNOSIS	$216.25	$43.25
Hospital	43239	UPPER STOMACH-INTESTINE SCOPE FOR BIOPSY	$251.15	$50.23
Hospital	43244	UPR GI NDSC BAND LIG ESOPHGL&/GSTR VARC	$233.67	$46.73
Hospital	43245	UPR GI NDSC DILAT GSTR OUTLET FOR OBSTRCJ	$148.87	$29.77
Hospital	43246	UPR GI NDSC DIRED PLMT PRQ GASTROSTOMY TUBE	$200.27	$40.05
Hospital	43247	STOMACH-INTESTINE SCOPE FOR FOREIGN BODY REMOVAL	$158.62	$31.72
Hospital	43248	UPR GI NDSC INSJ GD WIRE DILAT ESOPH > GD WIRE	$149.24	$29.85
Hospital	43249	UPR GI NDSC BALO DILAT ESOPH < 30 MM DIAM	$137.62	$27.52
Hospital	43250	UPR GI NDSC RMVL LES HOT BX/BIPOLAR CAUT	$149.64	$29.93
Hospital	43251	UPR GI NDSC RMVL TUM POLYP/OTH LES SNARE TQ	$172.38	$34.48
Hospital	43255	UPR GI NDSC CTRL BLD ANY METH	$223.14	$44.63
Hospital	43260	ERCP DX COLLJ SPEC BR/WA SPX	$274.63	$54.93
Hospital	43261	ERCP W/BX 1/MLT	$288.88	$57.78
Hospital	43262	ERCP W/SPHNCTROTOMY/PAPILLOTOMY	$338.80	$67.76
Hospital	43271	ERCP W/BALO DILAT AMPULLA BILIARY&/PNCRTC DUX	$339.02	$67.80
Hospital	43760	SURGICAL CHANGE OF STOMACH TUBE	$255.50	$51.10
Hospital	44360	SCOPE OF UPPER SMALL INTESTINE	$123.90	$24.78
Hospital	44376	ENTEROSCOPY > 2ND PRTN W/ILE +-COLLJ SPEC SPX	$241.07	$48.21
Hospital	44378	ENTEROSCOPY > 2ND PRTN ILE CTRL BLD	$326.38	$65.28
Hospital	44388	SCOPE OF COLON THRU OSTOMY FOR DIAGNOSIS	$251.02	$50.20
Hospital	44389	SCOPE OF COLON WITH BIOPSY THRU OSTOMY	$287.53	$57.51
Hospital	45330	DIAGNOSTIC SIGMOIDOSCOPY	$97.75	$19.55
Hospital	45331	SIGMOIDOSCOPY AND BIOPSY	$122.63	$24.53
Hospital	45334	SGMDSC FLX CTRL BLD	$129.06	$25.81
Hospital	45338	SGMDSC FLX RMVL TUM POLYP/OTH LES SNARE TQ	$277.71	$55.54
Hospital	45339	SGMDSC FLX ABLTJ LES	$241.69	$48.34
Hospital	45378	SCOPE OF COLON FOR DIAGNOSIS	$289.36	$57.87
Hospital	45379	COLSC FLX PROX SPLENIC FLXR RMVL FB	$367.68	$73.54
Hospital	45380	SCOPE OF COLON WITH BIOPSY	$346.29	$69.26
Hospital	45381	COLSC FLX PROX SPLENIC FLXR SBMCSL NJX	$335.83	$67.17
Hospital	45382	COLSC FLX PROX SPLENIC FLXR CTRL BLD	$453.60	$90.72
Hospital	45384	COLSC FLX PROX SPLENIC FLXR RMVL LES CAUT	$344.18	$68.84
Hospital	45385	COLSC FLX PROX SPLENIC FLXR RMVL LES SNARE TQ	$391.52	$78.30
Hospital	45386	COLSC FLX PROX SPLENIC FLXR DILAT BALO 1+ STRIXS	$474.25	$94.85
Hospital	46221	HEMORRHOIDECTOMY SMPL LIGATURE	$178.28	$35.66
Hospital	46500	NJX SCLRSG SLN HEMORRHOIDS	$149.28	$29.86
Hospital	46930	Destruction of internal hemorrhoid(s) by therma	$142.76	$28.55
Hospital	99223	1ST HOSP CARE PR D 70 MIN	$148.40	$29.68
Hospital	99232	SBSQ HOSP CARE PR D 25 MIN	$53.82	$10.76
Hospital	99233	SBSQ HOSP CARE PR D 35 MIN	$77.20	$15.44
Hospital	99238	HOSP DSCHRG D MGMT 30 MIN/<	$52.69	$10.54
Hospital	99252	Inpatient consultation low severity		$0.00	Invalid CPT for the year 2010
Hospital	99253	1ST INPT CONSLTJ 55 MIN		$0.00	Invalid CPT for the year 2010
Hospital	99254	1ST INPT CONSLTJ 80 MIN		$0.00	Invalid CPT for the year 2010
Hospital	99283	EMER DEPT MODERATE SEVERITY	$48.66	$9.73
Hospital	G0121	Screening Colonoscopy (low risk)	$281.04	$56.21

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.