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?