MEDICAID AND MEDICARE
MEDICAID
Medicaid is a program that pays for medical assistance for certain individuals and families with low incomes and resources. The Medicaid program is jointly funded by the federal and state governments to assist states in furnishing medical assistance to eligible needy persons. Medicaid is the largest source of funding for medical and health-related services for America’s poorest people. With broad national guidelines established by federal statutes, regulations and policies of each state:
• Establish its own eligibility standards
• Determine the type, amount, duration, and scope of services
• Set the rate of payment for services
• Administer its own program
MEDICARE
Medicare is a health insurance program for aged persons to complement the retirement, survivors and disability insurance benefits under Title II of the Social Security Act. Medicare covers persons age 65 and older. Persons under 65 may be covered if approved for disability or if they have certain diseases. Medicare consists of hospital insurance (Part A), supplemental medical insurance (Part B), prescription drug coverage (Part D), and Medicare Advantage plans, which offer beneficiaries a private health plan option.
MEDICARE BILLING COMPLIANCE
Filing false medical claims is a crime. The U.S. Department of Justice considers combating health care claims fraud and abuse among its top priorities. A false claim is when any statement made to secure reimbursement is inaccurate. This includes even seemingly minor errors, such as dates, provider numbers or places of service.
The most common types of fraud include:
• Billing for services not provided
• Misrepresenting the diagnosis
• Soliciting, offering, or accepting a kickback
• Unbundling charges
• Falsifying any medical documents or records
• Submitting duplicate reimbursement claims
• Billing for higher-level procedure than the one performed
26 La State Med Soc NEW PHYSICIAN’S GUIDE
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