Sunday, 25 June 2017


Controlling access to Medicare's computer systems by identifying and verifying persons who try to gain access reduces risk and potential adverse impact that unauthorized or malicious acts could have on the Medicare program.

Since 1990, Medicare has required physicians and other providers of medical services to submit claims directly to Medicare on behalf of beneficiaries. The increased workload and increasing complexity of procedure and diagnostic coding has encouraged physicians to turn to computer automation to improve efficiency.

Physicians and other medical service suppliers must be authorized to bill Medicare electronically. Each is given a unique number (submitter number) to use when submitting claims electronically. We were unable to determine how many electronic claims Medicare receives directly from physicians and other medical providers or from third parties billing on their behalf. We found that Medicare can identify providers who have requested and obtained a submitter number; however, this does not mean that the submitter number shown on a claim is actually the party that actually submitted claims to the Medicare system. An unknown number of providers allow billing companies to use their submitter number. Medicare assumes the provider is sending in claims when, in fact, anyone with a computer, modem and access to a provider's submitter number and patient's health insurance number could be sending claims to Medicare. The potential for misuse of submitter numbers is a vulnerability not adequately addressed by Medicare. 

Clearinghouses and Other Third-Party Billers   
Audit trails are necessary to trace the flow of data. They identify the source of the claim, and all persons or parties through whom the claim passed before it was received by Medicare.

Claims entering the Medicare program via a clearinghouse or billing agency do so using the provider’s submitter number. Consequently, Medicare is unable to identify most of the clearinghouses and billing agencies actually submitting claims to Medicare. 

We tried to determine how many claims enter the Medicare system from a third party only to discover that many carriers and intermediaries have no way of knowing who actually submitted the claim to Medicare. Inability to assess whether a claim came directly from a provider or passed through the hands of a third party represents a vulnerability in Medicare program safeguards. Medicare cannot determine whether claims enter their system from an authorized biller's site and computer or from unauthorized sites and computers. Billing companies, their employees and employees of providers have access to patient and provider information needed to access the Medicare system. This information can be used (without a providers knowledge) to generate false claims.

Locating information about clearinghouses, third-party billers or billing services is not easily done. A manual review of provider applications for a Medicare billing number will, in some cases, indicate that claims will be submitted to Medicare via a third party. Our experience, during other studies, is that the information in the carrier’s provider files is often obsolete or inaccurate.

Many clearinghouses and billing agencies use the same commercial billing software packages available to hospitals, physicians and other medical suppliers. Some have developed their own proprietary software. The vulnerabilities discussed in this report apply to all parties involved in Medicare claims preparation or submission. 

In an unrelated study, we were told by State Medicaid Agencies that third party billers and clearinghouses were an area of concern. Clearinghouses and third-party billers charge by the claim and States feel that this may serve as an incentive to split claims. At least one State was concerned that they did not know who actually submitted the claim or from where the claim was submitted. They felt that anyone with access to a physician’s electronic billing number and access to a telephone could submit false claims for payment. 

More than 30 billing individuals/entities have been excluded from participation in Medicare and State Medicaid programs. There are also a number of open criminal cases involving billing agency fraud. In most cases, these companies used the information they obtained from legitimate providers to prepare and submit false claims. In some cases, the billing companies totally fabricated claim information and billed for services not rendered. Other problems with billing companies include unbundling of services, upcoding, adding services and diagnostic information and billing more than one carrier for the same services provided to a patient.  

Tuesday, 20 June 2017

Medicare Secondary Payer

MAC Medicare Administrative Contractor 
Medical Necessity A medical procedure or service must be performed only for the treatment of an accident, injury or illness and is not considered experimental, investigational or cosmetic. 
Medi-Cal Medi-Cal is California’s Medicaid program. Provides health services for categorically eligible and low-income persons. 
Medicare A health insurance program for people age 65 and older, some people with disabilities under age 65, and people with end-stage renal disease (ESRD). Medigap Insurance provided by carriers to supplement the monies reimbursed by Medicare for medical services. 
Medigap is meant to fill this gap in reimbursement, so that the Medicare beneficiary is not at risk for the difference. 
Modifier In CPT coding, a two-digit add-on or five-digit number, representing the modifier, placed after the usual procedure code number. The two-digit modifier may be separated by a hyphen. 
MSP Medicare Secondary Payer

 N/C Non-Covered Charge -- Procedure is not covered by health plan.
 NPI National Identification Number – Standard unique 10-digit identifier assigned to health care providers by CMS. It replaces all previous identifiers. 

Palmetto GBA Effective September 2, 2008 Palmetto is the Medicare contractor for Jurisdiction 1 Part A/B. 
Participating Provider A physician or other medical provider has agreed to accept a set fee for services provided to members of a specific health plan.
 PCP Primary Care Physician -- The doctor you see first for most health problems and may talk with other doctors and health care providers about your care and refer you to them. 
POS Point of Service -- An insurance plan that allows a patient to choose doctors and hospitals without having to first get a referral from his/her primary care doctor. 
PPO Preferred Provider Organization -- A plan that contracts with independent providers at a discount for services. The physicians in a PPO are paid on a fee-for-service schedule that is discounted, usually about 10% to 20% below normal fees. A patient can use a physician outside of the PPO providers, but he or she will have to bear a bigger portion of the fee. 
Procedure Code CPT or HCPC code used to describe the service rendered. 
PTAN Provider Transaction Access Number -- Also known as your legacy Medicare number. 

RA Remittance Advice -- Supplied by the payer to outline payment for submitted claims. Also contains explanations for claim denials. Also referred to as EOB. 
Referral Permission from your primary care doctor for you to see a specialist or get certain services. Responsible Party The person(s) responsible for paying a patient’s office or hospital bill, usually referred to as the guarantor 

Secondary Insurance Extra insurance that may pay some charges not paid by the primary insurance company. 
Skilled Nursing Facility Typically an institution for convalescence or a nursing home. The skilled nursing facility provides a high level of specialized care for long-term or acute illness. It is an alternative to extended hospital stays or difficult home care. 
SOF Signature on File Supplemental Insurance An additional insurance company that handles claims for deductibles and coinsurance reimbursement. Many private insurance companies sell 
Supplemental Insurance for Medicare. 
Subscriber For group policies, subscriber is the term used to describe the employee. For individual policies, subscriber is the term to describe the policyholder. 

 TAR Treatment Authorization Request -- An authorization number given by insurance companies prior to treatment in order to receive payment for services rendered. 
Tele Comm Support Internet software or hardware support with the staff of Tele Comm Computer Systems, Inc. 
Term Date The date the insurance contract expired or the date a subscriber or dependent ceases to be eligible for coverage. 
TIN Tax Identification Number -- Also known as Employer Identification Number (EIN) 
TOS Type of Service -- A description of the category of the service preformed. 
TTY Teletypewriter for the hearing impaired 

Thursday, 15 June 2017

Glossary of Insurance and Medical Billing Terms

Deductible The amount an insured member must pay before the insurance company begins covering health care costs. 
DHS Department of Health Care Services for California 
Diagnosis Code ICD-9 code used to describe illness, injury or diseases 
DME Durable Medical Equipment 
DOS Dates of Service -- The date(s) when a patient was treated. 

 EDI Electronic Data Interchange
 EFT Electronic Funds Transfer -- A paperless computerized system enabling funds to be debited, credited, or transferred from the payer. 
EIN Employer Identification Number -- Also known as Tax Identification Number (TIN) 
EMR Electronic Medical Records -- Medical record in electronic format. 
EOB Explanation of Benefits -- Details regarding how your insurance company processed medical insurance claims, explains what portion of a claim was paid to the health care provider and what portion of the payment. 
EPSDT Early and Periodic Screening, Diagnosis, and Treatment -- A Medi-Cal program for individuals under the age of 21 who have full-scope Medi-Cal eligibility. This program allows for periodic screening to determine health care needs. 
ERA Electronic Remittance Advice -- Electronic file supplied by the payer to outline payment for submitted claims. Also known as an 835 file.

Fee for Service A method of payment for medical services rendered 
Fee Schedule A list of CPT codes and dollar amounts an insurance company will pay for a particular medical service
Formulary List of prescription drugs cost of which an insurance company will reimburse, or those that will provided free under a scheme. 

GPNet The EDI gateway to Palmetto GBA

 HCPCS Healthcare Common Procedure Coding System -- 5-digit alphanumeric set of procedure codes based on the AMA CPT codes. A standardized medical coding system for describing the specific items and services provided in the delivery of health services. Also known as a Procedure Code. 
HIPAA Health Insurance Portability and Accountability Act. This federal act sets standards for protecting the privacy of your health information. 
HL7 Health Level Seven -- A data exchange protocol and interface for medical records and billing software that allows different systems to interoperate. 
HMO Health Maintenance Organization -- An insurance plan that pays for preventative and other medical services provided by a specific group of participating providers.

ICD-9 International Classification of Diseases -- A standard format to describe the illness, injury or diseases by using a three digit code. Also known as a Diagnosis Code. 
IPA Independent Practice Association -- An organization of physicians who are contracted with an HMO plan 
IVR Interactive Voice Response -- Palmetto GBA 24 hour telephone line, obtain Medicare Part B information, such as claim status, last 3 checks issues, and eligibility. 

Jurisdiction 1 California, Hawaii, Nevada, Guam, American Samoa, Northern Mariana Islands

Sunday, 11 June 2017

Glossary of Insurance and Medical Billing Terms

Accept Assignment Provider has agreed to accept the insurance company allowed amount as full payment for the covered services. 

Adjudication The final determination of the issues involving settlement of an insurance claim. 

Allowed Amount The amount of the billed charge the insurance company deems is payable. 

AMA American Medical Association 

Ambulatory Care Any medical care delivered on an outpatient basis.

 Ancillary Services Services including laboratory, radiology, home health and skilled nursing facilities 

Assignment of Benefits The patient or guardian signs the Assignment of Benefits form so that the medical provider will receive the insurance payment directly. 

Authorization Approval from insurance company is required for patient to receive services. Prior Authorization may be necessary before hospital admission, or before care is given by non-HMO providers. 

Beneficiary Person covered by health insurance or Medicare benefits. 

Capitation A payment methodology in which the physician is paid a set dollar amount determined by per member per month calculation to deliver medical services to a specified group of people.

 CCS California Children Services -- A state program for children with certain diseases or health problems. 

CHDP Child Health and Disability Prevention Program -- A preventive program that delivers periodic health assessments and services to low income children and youth in California. 

Claim Response Report Palmetto GBA’s GPNet Claim Acceptance Response Report. This report is available for download immediately after claims submission. Report includes total claims submitted, accepted or rejected with error messages. 

Clearinghouse A company that, for a fee, electronically receives batches of claims from providers or billing centers and retransmits the data electronically to the designated payers. There is a contractual financial relationship between the clearinghouse and the payer. 

CMS Centers for Medicare & Medicaid Services -- Formally known as HCFA, CMS is responsible for oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. 

CMS 1450 UB-04 Uniform Bill formally known as UB-92 used for Institutional billing 

CMS 1500 The standard claim form used by health plans on which to consider payment to the medical provider

 COB Coordination of Benefits -- The process to determine the obligation of payers when a patient is covered under 2 separate health care plans to avoid duplicate payments for a single service or procedure.

 COBRA Consolidated Omnibus Budget Reconciliation Act -- Health insurance coverage that you can purchase when you are no longer employed, or awaiting coverage from a new insurance plan to begin. 

Contractual Adjustment A part of the charge that the provider or hospital must write off (not charge the patient) because of billing agreements with the insurance company.

 Co-Pay The portion of a claim that a member must pay out-of-pocket.

 CPT Code Current Procedural Terminology -- A 5-digit code used for describing the specific items and services provided in the delivery of health services. Also known as a Procedure Code. 

Wednesday, 7 June 2017

medical billing and coding

Skilled Nursing Facility​ - A nursing home or facility for convalescence. Provides a high level of specialized care for long-term or acutely ill patients. A Skilled Nursing Facility is an alternative to an extended hospital stay or home nursing care. 

SOF​ - Signature on File.

Software As A Service (SAAS)​ - One of the medical billing terms for a software application that is hosted on a server and accessible over the Internet. SAAS relieves the user of software maintenance and support and the need to install and run an application on an individual local PC or server. Many medical billing applications are available as SAAS. 

Specialist​ - Pphysician who specializes in a specific area of medicine, such as urology, cardiology, orthopedics, oncology, etc. Some health care plans require beneficiaries to obtain a referral from their primary care doctor before making an appointment to see a Specialist. 

Subscriber​ - Medical billing term to describe the employee for group policies. For individual policies the subscriber describes the policyholder. 

Superbill​ - One of the medical billing terms for the form the provider uses to document the treatment and diagnosis for a patient visit. Typically includes several commonly used ICD-9 diagnosis and CPT procedural codes. One of the most frequently used medical billing terms. 

Supplemental Insurance​ - Additional insurance policy that covers claims for deductibles and coinsurance. Frequently used to cover these expenses not covered by Medicare. 

TAR​ - Treatment Authorization Request. An authorization number given by insurance companies prior to treatment in order to receive payment for services rendered. 

Taxonomy Code​ - Specialty standard codes used to indicate a provider's specialty sometimes required to process a claim. 

Term Date​ - Date the insurance contract expired or the date a subscriber or dependent ceases to be eligible. 

Tertiary Insurance Claim​ - Claim for insurance coverage paid in addition to primary and secondary insurance. Tertiary insurance covers gaps in coverage the primary and secondary insurance may not cover. 

Third Party Administrator (TPA)​ - An independent corporate entity or person (third party) who administers group benefits, claims and administration for a self-insured company or group. 

TIN​ - Tax Identification Number. Also known as Employer Identification Number (EIN). 

TOP​ - Triple Option Plan. An insurance plan which offers the enrolled a choice of a more traditional plan, an HMO, or a PPO. This is also commonly referred to as a cafeteria plan. 

TOS​ - Type of Service. Description of the category of service performed. 

TRICARE​ - This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors. Formerly know as CHAMPUS. 

UB04​ - Claim form for hospitals, clinics, or any provider billing for facility fees similar to CMS 1500. Replaces the UB92 form. 

Unbundling​ - Submitting several CPT treatment codes when only one code is necessary. Untimely Submission​ - Medical claim submitted after the time frame allowed by the insurance payer. Claims submitted after this date are denied. 

Upcoding​ - An illegal practice of assigning an ICD-9 diagnosis code that does not agree with the patient records for the purpose of increasing the reimbursement from the insurance payor. UPIN​ - Unique Physician Identification Number. 6 digit physician identification number created by CMS. Discontinued in 2007 and replaced by NPI number. 

Usual Customary & Reasonable(UCR)​ - The allowable coverage limits (fee schedule) determined by the patient's insurance company to limit the maximum amount they will pay for a given service or item as defined in the contract with the patient. 

Utilization Limit​ - The limits that Medicare sets on how many times certain services can be provided within a year. The patient's claim can be denied if the services exceed this limit. 

Utilization Review (UR)​ - Review or audit conducted to reduce unnecessary inpatient or outpatient medical services or procedures. V-Codes​ - ICD-9-CM coding classification to identify health care for reasons other than injury or illness. 

Workers Comp​ - Insurance claim that results from a work related injury or illness. 

Write-off​ - Typically reference to the difference between what the physician charges and what the insurance plan contractually allows and the patient is not responsible for. May also be referred to as "not covered" in some glossary of billing terms. 

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