Chapter 2—Benefits and Coverage Under Part A and Part B
Chapter 3—Payment for Hospital Services
Chapter 4—Payment for Physician Services
Chapter 5—Payment for Other Items and Services
Chapter 6—Prescription Drug Benefit
Chapter 7—Medicare Advantage and PACE Plans
Chapter 8—Cost Reimbursement
Chapter 9—Conditions for Coverage and Payment
Chapter 10—Billing, Payment, and Charges
Chapter 11—Prohibited Acts and Penalties
Since the last edition of Medicare Law was published, the rules that govern Medicare have been changed substantially, with many of those changes being driven by the Affordable Care Act. The program structure has been altered somewhat, with the addition of new types of government contractors. From a coverage perspective, there are a number of new benefits available as well as new coverage rules. There are several new or modified payments systems that have been put into place. In addition, Medicare has tied its reimbursement rules much more closely to the quality of the services delivered than ever before, with significant reporting requirements now in place. The billing rules have been modified, including new time limits on the filing of claims, and the fraud and abuse rules have been strengthened. Finally, there are new payment approaches, such as Accountable Care Organizations, that are being or have been introduced. In short, our current Medicare system and its governing rules are quite different from those that were discussed in the last edition.
The American Health Lawyers Association is pleased to bring you the Third Edition of Medicare Law. Our tremendous thanks go to Editor-in-Chief Thomas W. Coons and author experts Rodney A. Johnson, Emily Jane Cook, John R. Hellow, David W. Hilgers, Elizabeth T. Thomas, Matthew Philip Utecht, Kathleen Ann Peterson, Anne W. Hance, Gary Scott Davis, Adam J. Rogers, Donald H. Romano, Robert L. Roth, William T. Mathias, and James F. Flynn. Their work, like that of the previous author Terry Coleman, leads you through the Medicare maze, from a discussion about the program's structure, to the critically important aspects of benefits, coverage, and eligibility.
Coverage includes in depth examination and discussion of:
• Payment for hospital services, including PPS and PPS-exempt hospitals
• Hospital payment methods
• The DRG system
• The urban/rural distinctions
• Outlier payments
• The physician fee schedule
• Cost reimbursement
• Prohibited acts under the Anti-Kickback and Stark Laws
• Administrative and judicial appeals processes; and
• The new incentive payment programs
This is the road map to a thorough understanding of Medicare, whether you are just beginning the journey or are continuing to learn about this complex and important aspect of healthcare law. Best of all, it is organized to facilitate an understanding of the program and provides citations to the underlying portions of the statute, regulations and manuals.