Decisions to Make regarding Medicare Open Enrollment

Seniors enrolling in Medicare for the first time or those wanting to make a switch in coverage can do so October 15 through December 7 every year. Why? Because this is the time when prescription and health care plans adjust costs, coverage options, and determine which pharmacies and providers are included in their networks for the coming year.

Therefore, the open enrollment period is the time when seniors or individuals with current Medicare plans can also change their current prescription or health care options and coverage, depending on need.

Comparing coverage plans

Medicare offers a variety of health and prescription coverage plans. Coverage and options differ between states, and sometimes even counties. For example, Medicare plan options can depend on whether you have a Medicare health plan such as a PPO, an HMO, or private fee-for-service plan, and whether you get help from Medicaid, supplemental security income, Medicare savings programs (MSP), or even support through Social Security.

Major components of Medicare include:Medicare and you

 Medicare Part A (Hospital insurance)
 Medicare Part B (Medical insurance)
 Medicare Part C (Medicare Advantage plans)
 Medicare Part D (Prescription drug coverage)

An individual receiving medical care may fall into coverage options offered through any of these parts or a combination of some of them. Billing and coverage questions, forms, and help determining which is which and what is covered when it comes to claims can be overwhelming for many seniors.

What about Medicare advantage plans?

Medicare Advantage plans cover the same and sometimes even more than ‘original’ Medicare, but have different premiums, deductibles, and co-pays based on plan. Medicare advantage plans include:

• HMO/HMOPOS – Health Maintenance Organization/Health Maintenance Organization Point of Service
• PPO – Preferred Provider Organization
• RPPO – Regional Preferred Provider Organization
• PFFS – Private Fee-For-Service
• MSA – Medicare Medical Savings Account
• EGWP – Employer Group Waiver Plan
• SNP – Special-Needs Plans

So what are my options?

Options for Medicare enrollment include:

• Making a change from one prescription plan to another (also includes joining or dropping a prescription plan)
• Switching from an original Medicare to a Medicare Advantage plan or vice versa
• Switching from one Medicare Advantage plan to another

Understanding the differences between options, health care plans, and making choices can be difficult, especially in today’s often convoluted healthcare environment. Individuals opting for Medicare for the first time should know that Medicare is not part of the health insurance marketplace rolled out under the Affordable Care Act, so you will not be dealing with any marketplace during the open enrollment period.

Individuals already enrolled in Medicare and who are satisfied with their services and coverage don’t need to do anything during the open enrollment period. However, changes in prescription policies are common. Review your prescription and other forms of coverage for next year to ensure you’ll be covered.

Consumers should note that if you are covered only under Medicare Part B (medical insurance) and don’t have Medicare Part A (Hospital insurance), you are not considered covered by the healthcare law’s requirements for health insurance.

What if I want to transition from the Marketplace to Medicare?

If you become eligible for Medicare after you have enrolled in the Marketplace, you can cancel your Marketplace coverage and enroll in Medicare during the open enrollment period. You may also take advantage of the initial enrollment period, which means that you can sign up for Medicare during a seven-month period of time that begins three months prior to the month you turn 65 years of age, during the month you  turn 65, and the following three months after you turn 65.

Yes, it can be confusing. Support and resources through the Alliance of Claim Assistance Professionals (ACAP) is available to first-time enrollees or others confused by what to do when assessing options during the open enrollment period to get the best coverage that meets your needs.

Transitioning Challenges Face many with Implementation of ICD-10

ICD 10 coding procedures were effectively initiated on October 1, 2015. For many, it’s about time that the United States medical system joined the rest of the world when it comes to coding practices. With its release, coding professionals can breathe a sigh of relief that the wait is over, but vast differences found between the two versions are causing confusion, frustration, and anxiety for many in healthcare.

During this transition, experts are expecting a greater number of denied claims to be bounced back to health care providers. What does that mean for you? Longer reimbursement time. More red tape. More phone calls and letters. More frustration.

Claims assistance professionals can reduce the number of denials of new claims filed after October 1, 2015 by organizing health insurance paperwork, reviewing claims for accurate coding, and directly deal with insurance companies and medical providers to ensure proper payment.

Why the change? Because after 30 years, medical treatments, knowledge, and technologies have advanced. The new coding procedures will enable doctors and hospitals to share more detailed information that ensures quality of care and plays a huge role in reimbursements for physicians and hospitals.

Over 100,000 new codes in ICD-10 provide challenges not only for billers and coders, but for doctors as well.

Bills with service dates after the October 1 implementation date must have ICD-10 codes or will be rejected or denied. Valid diagnostic codes will also be required in order to gain approval for many medical procedures and costly tests.

Brief history of ICD-10

A number of entities developed what was to become the International Classification of Diseases (ICD) starting in 1950, including the U.S. Public Health Service, the Veterans Administration, and Columbia Presbyterian Medical Center in New York. In 1966, the 8th version was published as the International Classification of Diseases, Adapted. Throughout the 1970s, other versions were published.

The World Health Organization (WHO) has been involved in creation of development of ICD publications since 1946 and helped develop the International Classification of Procedures in Medicine (ICPM) which was published in 1978. WHO was also involved with experimenting with alternative model structures for ICD-10.

The World Health Organization adopted ICD-10 in 1994. Since the mid-1990s and heading into the new millennium, a number of issues delayed the transition to ICD-10 in the US.

According to data gathered by the Workgroup for Electronic Data Interchange, delays have also affected readiness to implement the transition from ICD-9 to ICD-10. In March 2015, data was gathered among a small group of health care providers, health plans, and vendors. Less than one fourth of the physicians queried determined that they would be ready to implement ICD-10 by the October 1 compliance date. Approximately twenty-five percent claimed that they would be ready.

Ready or not, claims must be correct in regard to coding and accurate processing measures– if not, those claims will be delayed or denied.

Major differences between ICD-9 and ICD-10

Specificity is the name of the game with the new ICD 10 release. First, the basic and major differences between ICD-9 and ICD can include:

icd9 and ICD 10

In addition, codes for inpatient hospital procedures climbs from 4,000 to 87,000.

For example: a femur fracture using ICD-9 and ICD 10:

ICD-9 (Code 821.11) Open fracture of shaft a femur
(Number of codes for femur fracture? 16)

ICD-10 (S72.351C) Displaced, comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC
(Number of codes for femur fracture? 1,530)

ICD-10 coding define injuries based not on type of injury, but anatomical site. In addition, E and V codes are incorporated into ICD-10, and new code definitions bring the codes into the modern era. Certain disease processes have also been reclassified to new sections or chapters that reflect up-to-date medical knowledge.

Help and solutions for the challenging transition from ICD-9 to ICD-10 are available through the Alliance of Claim Assistance Professionals (ACAP). Whether you’re a patient or a provider, call on the experts to help with your medical claim issues.