Compare and contrast Medicare and Medicaid; including funding sources, fraud and/or abuse, and eligibility requirements for recipients: Medicare: A federal health insurance program for people who are 65 or older. Under 65 with certain / of any age and have End Stage Renal Disease (ESRD) or ALS. It is governed by the Federal Government and depending on the coverage you choose and may include: Care and services received as an inpatient in a hospital or skilled nursing facility (Part A)
Doctor visits, care and services received as an outpatient, and some preventive care (Part B)
Prescription drugs (Part D). (Part C) Medicare Advantage plans combine (Part A) and (Part B) coverage and often include drug coverage (Part D) as well - all in one …show more content…
Different programs under the Medicaid umbrella are designed to help people in specific populations. It is governed by which State you live in. Each state creates its own Medicaid programs, following federal guidelines. There are mandatory benefits and optional benefits. Mandatory benefits include in some parts care and services received in a hospital or skilled nursing facility. Care and services received in a federally-qualified health center, rural health clinic or freestanding birth center (licensed or recognized by your state). Doctor, nurse midwife, and certified pediatric and family nurse practitioner services and many more. The cose of Medicaid depends on your income and the rules in your state. Costs may include premiums, deductibles, copays, and coinsurance. Certain groups are exempt from most out-of-pocket costs. Eligibility depends on the rules in your …show more content…
When a doctor or medical specialist charges for services not done or upcharges the patient that is fraud. We as billers and coders have to keep our eyes open for anything we see that does not look right and report it immediately. Here is an article about the now Governer of the State of Florida and how he defrauded Medicare and Medicaid and how much he was fined but never charged with the crime:
A former accountant turned FBI whistleblower said Monday that he is convinced Gov. Rick Scott was well aware of widespread wrongdoing within his former hospital chain and was at one point a target of a federal criminal investigation. John Schilling, 52, a registered Republican from Naples, said that within six months of being hired at Columbia/HCA, Inc., in 1993, he found the company was preparing two sets of auditing books — one for submission to the federal government to obtain Medicare reimbursement and the other for internal recordkeeping that was stamped
Doctor visits, care and services received as an outpatient, and some preventive care (Part B)
Prescription drugs (Part D). (Part C) Medicare Advantage plans combine (Part A) and (Part B) coverage and often include drug coverage (Part D) as well - all in one …show more content…
Different programs under the Medicaid umbrella are designed to help people in specific populations. It is governed by which State you live in. Each state creates its own Medicaid programs, following federal guidelines. There are mandatory benefits and optional benefits. Mandatory benefits include in some parts care and services received in a hospital or skilled nursing facility. Care and services received in a federally-qualified health center, rural health clinic or freestanding birth center (licensed or recognized by your state). Doctor, nurse midwife, and certified pediatric and family nurse practitioner services and many more. The cose of Medicaid depends on your income and the rules in your state. Costs may include premiums, deductibles, copays, and coinsurance. Certain groups are exempt from most out-of-pocket costs. Eligibility depends on the rules in your …show more content…
When a doctor or medical specialist charges for services not done or upcharges the patient that is fraud. We as billers and coders have to keep our eyes open for anything we see that does not look right and report it immediately. Here is an article about the now Governer of the State of Florida and how he defrauded Medicare and Medicaid and how much he was fined but never charged with the crime:
A former accountant turned FBI whistleblower said Monday that he is convinced Gov. Rick Scott was well aware of widespread wrongdoing within his former hospital chain and was at one point a target of a federal criminal investigation. John Schilling, 52, a registered Republican from Naples, said that within six months of being hired at Columbia/HCA, Inc., in 1993, he found the company was preparing two sets of auditing books — one for submission to the federal government to obtain Medicare reimbursement and the other for internal recordkeeping that was stamped