The Centers for Medicare and Medicaid Services (CMS) has specific administrative rules that need to be followed in order for providers to bill and receive reimbursement for services. For this assignment, you will read three scenarios that demonstrate several key concepts of the Medicare and Medicaid programs and then answer questions pertaining to those scenarios.To complete this assignment, do the following:Use the scenarios in the document attachedType your responses to the questions beneath each scenario.
medicare_and_medicaid_administration.docx
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Medicare and Medicaid Administration Scenario Assignment
Advance Beneficiary Notice Scenario
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?
Medicare Eligibility Scenario
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.
Medicaid Services Scenario
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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