Medicare and Medicaid

Medicare and Medicaid are two different programs operated by the government. They are operated and funded by different parts of the government and primarily serve different groups. One serves people bove 65 the latter serves low income people. At times you can be eligible for both.

A patient presents to the hospital for an outpatient Magnetic Resonance Imaging (MRI) procedure. Upon arrival, the patient access registrar presents the patient with an Advance Beneficiary Notice (ABN). The ABN indicates that the diagnosis submitted by the provider does not meet Medicare criteria and will most likely be denied. The estimated cost of the procedure is $1800. What options does the patient have regarding the MRI?

 

At the time of each visit, the registrar needs to check the patient’s Medicare eligibility. The registrar needs to perform four tasks to validate eligibility on the initial encounter and periodically during subsequent visits. Name the tasks and indicate one reason why each step is important.

 

A patient received services performed by his primary care provider. The provider’s office filed the claim and it was denied by Medicaid indicating that preauthorization was not obtained prior to the performance of the procedure. What recourse does the provider have to obtain reimbursement for the services performed? Will the provider be allowed to bill the patient? Why or why not?

 

 

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