My name is Lucia Cardarelli, CPC. I am a Certified Professional Coder (CPC) and I worked for Centers for Medicare and Medicaid Services (CMS) for 35 years. My experience is in working for the Medicare Part B Contractor for the states of New Jersey, New York, Pennsylvania, DC, Delaware, and Maryland as Education and Training Consultant, training Physicians and their staff on Medicare rules and regulations and how to complete a claim form for their patients.
So I know a lot about Medicare but I don't know everything there is to know about it. No one does. Since I've retired with all this knowledge - knowledge that so many people need and want - I've found that I'd like to share what I know with as many people as I can.
Here's some general information about the Medicare Program.
Medicare is a Federal Health Insurance Program for people age 65 or older, people under age 65 with certain disabilities, people of any age with End Stage Renal Disease (ESRD) permanent kidney failure requiring dialysis or a kidney transplant.
Medicare should be a National Program but - though most people don't realize this - it is not. The Medicare program is administered by Medicare Administrative Contractors (MAC) Authority.
These contractors (insurance companies) bid for the contract for a large region which is controlled by CMS.
Therefore it is very difficult to know the Rules and Regulations for each state in the United States. The rule of thumb from CMS is that if the service that the beneficiary (patient) has had is a general service i.e., lab work, vaccine injections, then the guidelines will be the National Coverage Determination (LCD) and it effects everyone no matter what state they live.
If the service is not a general service, like certain specialty exams, certain surgical procedures, certain illness i.e., cancer, diabetes, etc, then the rule will be the Local Coverage Determination (LCD). Therefore, it will be the rules and regulations of the Contractors that administers the Medicare Program for that region which includes several states.
Every insurance company that administers the Medicare Program for different states have different rules and regulations that they use for their Non-Medicare Patients.
Therefore, the questions that I will answer for you will be the general questions, because any claim issues will be very difficult to answer without very detailed research for that particular Contractor and their Local Coverage Determinations (policy) for that particular service.
There are different parts to Medicare:
Part A (Intermediary) COVERS:
Inpatient Care in Hospitals
Hospice Care
Inpatient Care in a skilled Nursing Facility (Not custodial or long term care)
Home Health Care
Part B (Contractor) COVERS:
Professional services of a Physician
Preventive Services
Outpatient Care
Part D (Contractor) COVERS:
Prescriptions
DME (Durable Medical Equipment) (Contractor) COVERS:
all durable medical equipment prescribed and certified for medical necessity by the patient’s physician.
All of these intermediaries and contractors are administered by different insurance companies that have won the bids to administer the program, therefore different rules and regulations will apply in different cases.
I will, to the best of my ability, answer questions that are general in nature and fall under the NCD (national coverage determination) national policy.
If I can't answer the question myself, I will point you in the direction of where you might find the answer.
SOME PHONE NUMBERS TO ANSWER YOUR PERSONAL QUESTIONS:
1. MEDICARE 1-800-633-4227 To get general Medicare information
2. STATE HEALTH INSURANCE 1-800-633-4227 ASSISSTANCE PROGRAM (SHIP) To get free Medicare counseling and personalized help
3. SOCIAL SECURITY 1-800-772-1213 To replace a Medicare card, change your address or name
4. COORDINATION OF BENEFITS 1-800-999-1118 To get information on whether Medicare or your other insurance pays first and to report changes in your insurance information
5. DEPARTMENT OF HEALTH AND 1-800-447-8477 HUMAN SERVICES – OFFICE OF INSPECTOR GENERAL If you suspect billing FRAUD
6. DEPARTMENT OF VETERANS 1-800-827-1000 AFFAIRS
If you are a veteran or have served In the U.S. military.
7. RAILROAD RETIREMENT BOARD 1-877-772-5772
If you have benefits from the Railroad Retirement Board
If you need assistance with your prescription program, call your state’s Department on Aging and ask for information on “State Prescription Assistance Program”.
This is a State Program for individuals with limited income. This means ONLY monthly income NOT assets that you have, i.e. house, bonds, stocks, cd’s, etc.
My name is Lucia Cardarelli, CPC. I am a Certified Professional Coder (CPC) and I worked for Centers for Medicare and Medicaid Services (CMS) for 35 years. My experience is in working for the Medicare Part B Contractor for the states of New Jersey, New York, Pennsylvania, DC, Delaware, and Maryland as Education and Training Consultant, training Physicians and their staff on Medicare rules and regulations and how to complete a claim form for their patients.
