CSPR HFMA QUESTIONS AND ANSWERS SURE A+
✔✔Medicare Outpatient Observation Notice (MOON) -✔✔-requires hospitals and
Critical Access Hospitals (CAH) to provide notification to individuals receiving
observation services as outpatients for more than 24 hours explaining the status of the
individual as an outpatient, not an inpatient, and the implications of such status.
-Requirements - The MOON must be provided no later than 36 hours after observation
services are initiated or, if sooner, upon release. An oral explanation of the MOON must
be provided, ideally in conjunction with the delivery of the notice, and a signature must
be obtained from the individual, or a person acting on such individual's behalf, to
acknowledge receipt. In cases where such individual or person refuses to sign the
MOON, the staff member of the hospital or CAH providing the notice must sign the
notice to certify that notification was presented.
✔✔Advanced Beneficiary Notice (ABN): Potential Service Denials -✔✔Although
typically covered by Medicare, the following services are likely to be denied for lack of
medical necessity under the circumstances described below:
-Lab Tests - Lab tests (for example, complete blood count) when the diagnosis code
does
not support Medicare's definition of medical necessity.
-Pap Smear - A screening Pap smear and pelvic exam given more often than every two
years, unless the beneficiary is in a category for which annual exams are covered
-Screening Fecal Occult Blood Test - A screening fecal occult blood test given more
often
than annually or if the beneficiary is younger than 50 years
-Screening flexible sigmoidoscopy - A screening flexible sigmoidoscopy given more
often
than every four years or if the beneficiary is younger than 45 years
-Prostate Cancer Screening - A prostate cancer screening test given more often than
annually or if the beneficiary is younger than 50 years
-Tetanus vaccine - A tetanus vaccine given prophylactically (as compared to one given
because the patient stepped on a rusty nail)
-Local Medical Review Policy (LMRP) - Any service that does not meet the coverage
criteria
, established in Local Medical Review Policy (LMRP). Some Medicare carriers have
established
specific coverage criteria. For example, some carriers have established LMRPs for
common
office procedures such as removal of benign skin lesions. You can find LMRPs through
the
website of your local Medicare carrier.
✔✔The various regulatory agencies in the healthcare industry include the following: -
✔✔-Centers for Medicare and Medicaid Services (CMS)
-Federal Trade Commission (FTC)
-Internal Revenue Service (IRS)
-Office of the Inspector General (OIG)
-Department of Justice (DOJ)
-Securities and Exchange Commission (SEC)
-The U.S. Public Health Service (PHS)
✔✔Managed Medicare enrollees now enjoy patient protections such as the following: -
✔✔a) Information disclosure
b) Choice of providers and plans
c) Access to emergency services
d) Participation in treatment decisions
e) Financial disclosure
f) Respect and nondiscrimination
g) Confidentiality of health information
h) Complaints and appeals
✔✔Tiering -✔✔Tiering can be thought of as the ranking or classifying of one or more of
the provider
delivery system components or benefit design components of a typical managed care
plan
to influence choice.
✔✔Tiered Provider Networks -✔✔-Delivery network tiering is an effort by insurers to rein
in costs and to address calls from employers and the public for improved quality.
-Tiered networks were first introduced after the cost-cutting success of tiered pharmacy
plans and formularies
✔✔Steps used to control costs of managed care include the following: -✔✔-One step ‐
For the payer and provider to agree on reasonable payment for each service. In
general, this payment arrangement results in payment rates that are beneath the rates
that a provider would charge to an uninsured individual.
-A next step ‐ Might include combining services that are typically provided in conjunction
with one another and bundling the associated charges and determining an appropriate
charge for that set of services or type of care.
✔✔Medicare Outpatient Observation Notice (MOON) -✔✔-requires hospitals and
Critical Access Hospitals (CAH) to provide notification to individuals receiving
observation services as outpatients for more than 24 hours explaining the status of the
individual as an outpatient, not an inpatient, and the implications of such status.
-Requirements - The MOON must be provided no later than 36 hours after observation
services are initiated or, if sooner, upon release. An oral explanation of the MOON must
be provided, ideally in conjunction with the delivery of the notice, and a signature must
be obtained from the individual, or a person acting on such individual's behalf, to
acknowledge receipt. In cases where such individual or person refuses to sign the
MOON, the staff member of the hospital or CAH providing the notice must sign the
notice to certify that notification was presented.
✔✔Advanced Beneficiary Notice (ABN): Potential Service Denials -✔✔Although
typically covered by Medicare, the following services are likely to be denied for lack of
medical necessity under the circumstances described below:
-Lab Tests - Lab tests (for example, complete blood count) when the diagnosis code
does
not support Medicare's definition of medical necessity.
-Pap Smear - A screening Pap smear and pelvic exam given more often than every two
years, unless the beneficiary is in a category for which annual exams are covered
-Screening Fecal Occult Blood Test - A screening fecal occult blood test given more
often
than annually or if the beneficiary is younger than 50 years
-Screening flexible sigmoidoscopy - A screening flexible sigmoidoscopy given more
often
than every four years or if the beneficiary is younger than 45 years
-Prostate Cancer Screening - A prostate cancer screening test given more often than
annually or if the beneficiary is younger than 50 years
-Tetanus vaccine - A tetanus vaccine given prophylactically (as compared to one given
because the patient stepped on a rusty nail)
-Local Medical Review Policy (LMRP) - Any service that does not meet the coverage
criteria
, established in Local Medical Review Policy (LMRP). Some Medicare carriers have
established
specific coverage criteria. For example, some carriers have established LMRPs for
common
office procedures such as removal of benign skin lesions. You can find LMRPs through
the
website of your local Medicare carrier.
✔✔The various regulatory agencies in the healthcare industry include the following: -
✔✔-Centers for Medicare and Medicaid Services (CMS)
-Federal Trade Commission (FTC)
-Internal Revenue Service (IRS)
-Office of the Inspector General (OIG)
-Department of Justice (DOJ)
-Securities and Exchange Commission (SEC)
-The U.S. Public Health Service (PHS)
✔✔Managed Medicare enrollees now enjoy patient protections such as the following: -
✔✔a) Information disclosure
b) Choice of providers and plans
c) Access to emergency services
d) Participation in treatment decisions
e) Financial disclosure
f) Respect and nondiscrimination
g) Confidentiality of health information
h) Complaints and appeals
✔✔Tiering -✔✔Tiering can be thought of as the ranking or classifying of one or more of
the provider
delivery system components or benefit design components of a typical managed care
plan
to influence choice.
✔✔Tiered Provider Networks -✔✔-Delivery network tiering is an effort by insurers to rein
in costs and to address calls from employers and the public for improved quality.
-Tiered networks were first introduced after the cost-cutting success of tiered pharmacy
plans and formularies
✔✔Steps used to control costs of managed care include the following: -✔✔-One step ‐
For the payer and provider to agree on reasonable payment for each service. In
general, this payment arrangement results in payment rates that are beneath the rates
that a provider would charge to an uninsured individual.
-A next step ‐ Might include combining services that are typically provided in conjunction
with one another and bundling the associated charges and determining an appropriate
charge for that set of services or type of care.
