Month: November 2017

Developmental Disabilities – A severe, chronic disability of a person 5 years of age or older which:

(a) Is attributable to a mental or physical impairment or is a combination of mental and physical impairments;

(b) Is manifested before the person attains age twenty-two;

(c) Results in substantial functional limitations in three or more of the following areas of major life activity:

• (I) self care;
• (ii) receptive and expressed language;
• (iii) learning;
• (iv) mobility;
• (v) self direction;
• (vi) capacity for independent living; and
• (vii) economic self sufficiency;

and (e) reflects the person’s need for a combination and sequence of special, interdisciplinary or generic care, treatment or other services which are lifelong or extended duration and are individually planned and coordinated; except that such term, when applied to infants and young children (meaning individuals from birth to age 5, inclusive),who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in developmental disabilities if services are not provided.

Further reading –

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/ICFMR_Glossary.pdf

Durable Medical Equipment – Medicare Part B (Medical Insurance) covers medically necessary durable medical equipment (DME) that your doctor prescribes for use in your home. Only your doctor can prescribe medical equipment for you. DME meets these criteria:

Durable (can withstand repeated use)
Used for a medical reason
Not usually useful to someone who isn’t sick or injured
Used in your home
Has an expected lifetime of at least 3 years

Further reading –

https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center.html

Fraud & Abuse – Medicare and Medicaid fraud, waste, and abuse affect every American by draining critical resources from our health care system, and contribute to the rising cost of health care for all. Taxpayer dollars lost to fraud, waste, and abuse harm multiple parties, particularly some of our most vulnerable citizens.

Fraud occurs when someone intentionally executes or attempts to execute a scheme to obtain money or property of any health care benefit program. The primary difference between fraud and abuse is intention.

Abuse occurs when health care providers or suppliers perform actions that directly or indirectly result in unnecessary costs to any health care benefit program. While some fraud schemes may involve legitimate care, some fraud schemes never involve real care, such as false storefronts pretending to operate a business.

Each working day, Medicare processes over 4.6 million claims, of which 200,000 are for durable medical equipment, from a total of 1.5 million fee-for-service providers.

Each year, Medicaid processes 3.9 billion claims, representing more than $430 billion paid annually, for more than 57 million beneficiaries.

Further reading –

https://www.cms.gov/Outreach-and-Education/Look-Up-Topics/Fraud-and-Abuse/Fraud-page.html

Federally Qualified Health Center – is a community-based organization that provides comprehensive primary care and preventive care, including health, oral, and mental health/substance abuse services to persons of all ages, regardless of their ability to pay or health insurance status. Thus, they are a critical component of the health care safety net.[1] FQHCs are called Community/Migrant Health Centers (C/MHC), Community Health Centers (CHC), and 330 Funded Clinics. FQHCs are automatically designated as health professional shortage facilities.

Further reading –

https://en.wikipedia.org/wiki/Federally_Qualified_Health_Center

National Institute on Aging – NIA, one of the 27 Institutes and Centers of NIH, leads a broad scientific effort to understand the nature of aging and to extend the healthy, active years of life. NIA is the primary Federal agency supporting and conducting Alzheimer’s disease research.

Further reading –

https://www.nia.nih.gov/

Medicare Benefit Notice – A notice you get after your doctor files a claim for Part A services in the Original Medicare Plan. It says what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay. You might also get an Explanation of Medicare Benefits (EOMB) for Part B services or a Medicare Summary Notice (MSN). (See Explanation of Medicare Benefits; Medicare Summary Notice.)

Further reading –

https://www.cdc.gov/nhsn/pdfs/newsletters/june-2014.pdf