ADDENDUM A Medicare Key Terms, Sources of Law and Resource Guide

Transcription

1 ADDENDUM A Medicare Key Terms, Sources of Law and Resource Guide MEDICARE SPEAK The following is a brief functional overview of the countless phrases, acronyms, abbreviations, and designations that have evolved over the years into the distinct linguistic system (commonly known as MedicareSpeak ) that dominates the communications landscape of providers: Acts/Laws/Programs (Frequently Referred To) ARRA American Recovery and Reinvestment Act of 2009 ACA Affordable Care Act of 2010 BBA The Balanced Budget Act of 1997 BBRA The Balanced Budget Refinement Act of 1999 BIPA Benefit Improvement and Protection Act of 200 COBRA Consolidated Omnibus Budget Reconciliation Act of 1985 DEFRA Deficit Reduction Act of 1984 DRA Deficit Reduction Act of 2005 HCERA Health Care and Education Reconciliation Act of 2010 HIPAA Health Insurance Portability and Accountability Act MMA Medicare Modernization Act of 2003 MIPPA Medicare Improvements for Patients and Providers Act of 2008 OBRA (yr) Omnibus Budget Reconciliation Act ( 86, 87, 89, 90, 93, 99 and 00) PPACA Patient Protection and Affordable Care Act of 2010 SSA Social Security Act SSI Supplemental Security Income Stark I & II Physician Self Referral Laws part of OBRA 89 and 93, respectively TEFRA Tax Equity and Fiscal Responsibility Act of 1982 Relevant Agencies, Departments, Commissions And Participants ALJ Administrative Law Judge AMA American Medical Association CMS Centers for Medicare and Medicaid Services (f/k/a as the Health Care Financing Administration or HCFA) DAB Departmental Appeals Board HHS or DHHS U.S. Dept. of Health and Human Services (also DHHS) IPAB Independent Payment Advisory Board MedPAC Medicare Payment Advisory Commission MGCRB Medicare Geographic Classification Review Board OIG Office of Inspector General OMB Office of Management and Budget PRO Peer Review Organization PPRC Physician Payment Review Commission (also PhyPRC) PRRB Provider Reimbursement Review Board PSRO Professional Standards Review Organization Commonly Used Terms And Descriptors AAPCC Adjusted Average Per Capita Cost ACO Accountable Care Organization ACR Adjusted Community Rate ALOS Average Length of Stay APC Ambulatory Payment Class APG Ambulatory Patient Group AVG Ambulatory Visit Group (as opposed to average) CAH Critical Access Hospital CIA Corporate Integrity Agreement 1

2 CF Conversion Factor CMHC Community Mental Health Center CMI Case Mix Index also Center for Medicare and Medicaid Innovation CMP Competitive Medical Plan CoP Conditions of Participation CORF Comprehensive Outpatient Rehabilitation Facility CPI Consumer Price Index CPR Customary, Prevailing and Reasonable CPT Current Procedural Terminology CRNA Certified Registered Nurse Anesthetist DMEPOS Durable Medical Equipment Prosthetics Orthotics & Supplies DRG Diagnosis Related Group DSA Disproportionate Share Adjustment DSH Disproportionate Share Hospital E&M Evaluation and Management EACH Essential Access Community Hospital EOB Explanation of Benefits ESRD End Stage Renal Disease FFS Fee for Service FI Fiscal Intermediary FQHC Federally Qualified Health Center GAF Geographic Adjustment Factor GME Graduate Medical Education GPCI Geographic Practice Cost Index (pronounced gypsy ) HCPCS HCFA Common Procedure Coding System HHA Home Health Agency HHRG Home Health Resource Group HI Hospital Insurance (Part A Trust Fund) HMO Health Maintenance Organization HPB Historic Payment Basis HSR Hospital Specific Rate ICD 9 CM International Classification of Diseases, Ninth Revision, Clinical Modification IDTF Independent Diagnostic Testing Facility IME Indirect Medical Education IPL Independent Physiological Laboratory IRF Inpatient Rehabilitation Facility JCAHO Joint Commission on Accreditation of Healthcare Organizations LCC Lower of Cost or Charges LMRP Local Medical Review Policy LTAC Long Term Acute Care Hospital MAPDP Medicare Advantage Prescription Drug Plan MDC Major Diagnostic Category MDH Medicare Dependent Hospital MEI Medical Economic Index MED PAR Medicare Provider Analysis and Review MEI Medical Economic Index MFS Medicare Fee Schedule MSA Metropolitan Statistical Area, also Medical Savings Account NonPARs Nonparticipating Physicians NPI National Provider Identifier NPR Notice of Program Reimbursement NPRM Notice of Proposed Rule Making OPD Outpatient Departure OPO Organ Procurement Organization PARs Participating Physicians PC Professional Component PDP Prescription Drug Plan PIN Provider Identification Number 2

3 POS Point of Service PPIS Physician Practice Information Survey PPO Preferred Provider Organization PPS Prospective Payment System PSO Provider Sponsored Organization QI Qualified Individual QMB Qualified Medicare Beneficiary RBRVS Resource Based Relative Value Scale RHC Rural Health Clinic RUG Resource Utilization Group RVU Relative Value Unit SCH Sole Community Hospital SGR Sustainable Growth Rate SLMB Specified Low Income Medicare Beneficiary SMI Supplemental Medical Insurance SNF Skilled Nursing Facility SSA Social Security Act TC Technical Component TPA Third Party Administrator UCDS Uniform Clinical Data Set UPIN Unique Provider Identification Number MEDICARE LAW Part A, General Provisions; Part B Peer Review of Utilization and Quality of Health Care Services; and Administrative Simplification: Social Security Act (SSA ; 42 U.S.C d-8) Health Insurance for the Aged and Disabled; Part A: Hospital Insurance Benefits; Part B Supplemental Medical Insurance Benefits for the Aged and Disabled; Provisions Relating to the Administration of Part B, Payment for Physicians Services; Part C Medicare Advantage Program; Part D Voluntary Prescription Drug Program; Part E Miscellaneous Provisions. SSA ; 42 U.S.C. 1395) MEDICARE REGULATIONS 42 C.F.R. Parts ; Regulations, generally 42 C.F.R. Parts Coverage, generally 42 C.F.R. Parts Certification 42 C.F.R. Parts ; ; 424 Payment, generally 42 C.F.R. 406 Part A Eligibility 42 C.F.R. 407 Part B Eligibility 42 C.F.R. 411 Exclusions from Medicare Payment including Stark law provisions 42 C.F.R. 412 Inpatient Hospital PPS 42 C.F.R. 413 End Stage Renal Disease 42 C.F.R. 416 Ambulatory Surgery Services 42 C.F.R. 420 Program Integrity 42 C.F.R. 422 Medicare Advantage Program 42 C.F.R. 423 Part D Rules and Regulations 42 C.F.R. 424 Conditions for Medicare Payment 42 C.F.R OIG Regulations including AKBS Safe Harbor Provisions MEDICARE MANUALS In addition to publishing implementing regulations in the Federal Register, CMS publishes additional interpretative guidelines though various administrative manuals. Medicare manuals are a repository of operating instructions, policies, and procedures to administer CMS programs. The manuals are based on interpretations of statutes and regulations and were drafted for CMS agencies, contractors, and State survey agencies. The manuals are useful for many as source of technical and professional information about the Medicare and Medicaid programs. 3

4 CMS has transitioned to Internet-only manuals (IOMs). Unlike the paper-based manuals, the new CMS manual system is organized by functional area (i.e., program integrity, eligibility, entitlement, claims processing, etc.). The IOM manuals include the following: Medicare General Information, Eligibility and Entitlement Manual Medicare Benefit Policy Manual Medicare National Coverage Determinations (NCD) Manual Medicare Claims Processing Manual Medicare Secondary Payer Manual Medicare Financial Management Manual State Operations Manual Medicare Program Integrity Manual Medicare Contractor Beneficiary and Provider Communications Manual Quality Improvement Organization Manual Programs of All-Inclusive Care for the Elderly (PACE)Manual State Medicaid Manual (under development) Medicaid State Childrens Health Insurance Program (Under Development) Medicare ESRD Network Organizations Manual Medicaid Integrity Progarm (MIP) Medicare Managed Care Manual CMS/Business Partners Systems Security Manual Medicare Prescription Drug Benefit Manual Demonstrations The older paper based manuals include the following: Coverage Issues Manual - CMS Pub 6 State Operations Manual - CMS Pub 7 Outpatient Physical Therapy, Comprehensive Outpatient Rehabilitation Facility and Community Mental Health Center Manual - CMS Pub 9 Hospital Manual - CMS Pub 10 Home Health Agency Manual - CMS Pub 11 Skilled Nursing Facility Manual - CMS Pub 12 Medicare Intermediary Manual - CMS Pub 13 Medicare Carriers Manual - CMS Pub 14 Provider Reimbursement Manual - CMS Pub 15 Peer Review Organization Manual - CMS Pub 19 Hospice Manual - CMS Pub 21 Regional Office Manual - CMS Pub 23 State Buy In Manual - CMS Pub 24 Carrier QA Handbook - CMS Pub 25 Rural Health Clinic Manual - CMS Pub 27 Renal Dialysis Facility Manual - CMS Pub 29 Christian Science Sanatorium Hospital Manual Supplement - CMS Pub 32 State Medicaid Manual - CMS Pub 45 HMO / CMP Manual - CMS Pub 75 Federally Qualified HMO Manual - CMS Pub 77 End Stage Renal Disease Manual - CMS Pub 81 NATIONAL COVERAGE DECISIONS (NCDs). NCDs set forth whether Medicare will cover specific services, procedures or technologies on a national basis based on a reasonableness standard. NCDs do not make determinations on codes assigned to a service or the amount of payment to be made for the service. An NCD is binding on all Medicare contractors, including, but not limited to, MACs, Medicare carriers, fiscal intermediaries, and QIOs. The Medicare contractor must make the coverage decision if an NCD does not specifically exclude an indication or circumstance, or if the item or service is not mentioned 4

5 in an NCD or Medicare manual. NCDs are located on the CMS Medicare Coverage Homepage website at LOCAL COVERAGE DETERMINATIONS (LCDs). An LCD is a determination by a MAC which focuses exclusively on whether a particular service is reasonable and necessary. An LCD does not include a determination (1) of which procedure code, if any, is assigned to a service, or (2) with respect to the amount of payment to be made for the service. IMPORTANT WEBSITES & LINKS Social Security Administration (SSA) U.S. Dept. of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) Consumer Medicare Information HHS Office of Inspector General (OIG) U.S. Dept. of Justice (DOJ) The Federal Register Government Printing Office The Federal Register Federal Register Advance Desk CMS Medlearn Matters: Learning-Network-MLN/MLNMattersArticles/ Congressional Budget Office (CBO) General Accounting Office (GAO) Office of Management and Budget (OMB) House Budget Committee House Committee on Ways and Means House Committee on Energy and Commerce Senate Committee on Finance 5