5) Medicare Flashcards
Center for Medicare and Medicaid (CMS)
Part of the executive branch, which promulgates regulations
What are MAC’s?
They’re the ones who actually do the billing, reimbursements, etc
- The way they interpret the law can sometimes be problematic
- Local govt
MedPAC
Advisory group to Congress
What individuals under the age of 65 can get Medicare coverage?
- Permanently disabled
- Have end-stage renal disease
- Have ALS
Where do most Medicare pt’s live?
At home
Why does Medicare have high cost-sharing responsibilities and what does this mean for Medicare households?
There’s limit to out-of-pocket pay so households tend to have high spending patterns
What is a pro and con Medicare Part C (Medicare Advantage)?
- Pro = Less expensive
- Con = Restrictive to pt’s
True or False: Its illegal for Medicare to pay a provider if they don’t submit the proper documentation
True
What do providers need to submit to Medicare in order to get reimbursed?
Claims Form
Explain how Medicare provider payment works
They pre-determine a base payment for a given service and then make adjusts based on variables such as:
- Geographic location
- Pt complexity
Explain Medicare payments for acute care hospitals
- Use PPS
- Base rate is based on DRG’s and then adjusted for pt complexity
- Teaching hospitals or those in low-income areas sometimes receive more payments
- Can receive penalties for poor quality
How are IRF’s paid?
Based on a pt case mix
CMS 60% Rule
Facility needs to prove that at least 60% of admissions meet the qualifying conditions
Explain SNF payment
- Paid through one of 66 pre-determined RUG’s for each pt, based on expected level of care
- MDS is used to assess pt level
- Measured in minutes of care
- Additional money is added to pay for the care of those w/AIDS
- Operation and capital costs are included
- Requires physician oversight
What 4 criterion need to be met in order for Medicare to pay for care received in an SNF?
1) Pt requires skilled nursing, rehab, etc
2) Pt requires skilled services on a daily basis
3) Daily skilled care can be provided on an inpatient basis only
4) Services must be reasonable and necessary
How many minutes of rehab are needed for each RUG classification?
- Ultra High = >720min in at least 2 disciplines
- Very High = 500min in at least 1 discipline
- High = 325 minutes in at least 1 discipline
- Medium = >150min in an combo of 3 disciplines
- Low = 45min 3 days/wk in any combo of 3 disciplines and 2+ rehab/nursing services
What are the rules to have Medicare Part A cover home health?
- Pt must be housebound after initial hospitalization
- Pt requires part-time initial skilled care
- Care must be directed by a physician
- Care must be provided by a Medicare-certified home health agency
- Will cover 1st 100 days after a 3-day hospital stay
What is used to assign a pt to a home health resource group?
The OASIS
How long is the basic unit of payment for home health?
60 days
What can cause the home health case rate to change and what occurs as a result?
- Pt reaches goals → Partial episode payment
- Pt change from initial POC → “Significant change in condition”adjustment
When can Medicare Part B be used for home health?
- When 100 day Part A benefit expires
- 3-day hospital stay requirement not met
Describe Medicare Hospice Payment
- Paid through Part A
- Pt needs to prove they have <6mo to live
- Pt needs to receive care from a Medicare-approved hospice
- Pt has to sign a form that they are going to receive hospice benefits and thus no longer submit to Medicare for other services
- Considered bundled payment
- Agencies are paid a daily rate
- Payments are based on the level of care
How is payment decided for outpatient providers?
Based on a Medicare Fee Schedule
What 3 settings make up the majority of utilized outpatient services?
1) Private Practice
2) SNF
3) Hospital OP
Resource-Based Relative Value Scale (RBRVS)
Price of services should be based on the cost associated w/providing that service
- Basis for outpatient payment
For PT services, who determines medical necessity and how do they do this?
The evaluating PT → Through clear evidence in documentation
What makes something a “skilled service”?
When the knowledge, abilities, and clinical judgment of a PT are necessary to safely and effectively administer PT service to:
- Improve an impairment or fxnl limitation
- Maintain fxnl status
- Prevent/slow further decline in fxn
What happens a pt is judged safe and the skill of a PT and services are no longer necessary or reasonable?
You can no longer bill for services bc its not skilled care
Can you bill for care by an aide?
No
Can you bill for an independent activity?
No
Can you bill for the performance of a mastered task?
No
Can you bill for a continued repetitive maintenance program and why?
No → Need to have some variation
Certification
Physician’s/NPP approval of the POC
- Dated signature
Non-Physician Practitioner (NPP)
PA, clinical nurse specialist, or nurse practitioner who may certify if permitted by state and local laws
Who is considered a qualified professional and what does this mean?
PT, OP, SLP, NP, CNS, MD, PA → They can bill for therapeutic services
Define Orders/Referrals/Need for Care and describe its role in payment.
Provides evidence that the pt needs care and that they are under the care of a physician
- Not in effect until the physician certifies the POC
- Payment is dependent upon POC certification
At what point do POC’s need to be established?
Before tx begins
Can eval and tx occur on the same day and be billable?
Yes
What happens w/non-covered services?
Provider can directly bill the pt
- Statutorly - Not covered bc its out of Medicare’s scope but PT feels it is necessary and pt consents to it
- Not covered bc its not medically necessary
Explain billing Medicare for care administered by a PTA
- Billable
- Must be supervised a PT (or follow state practice act)
- Anything outside of PTA’s scope of practice is not billable
Can an HCP get a Therapy Cap exception? If so, what’s the process?
- Use a KX modifier
- Clinician can show medical necessity
- Beneficiary must meet other requirements for therapy
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
- Repealed the sustainable growth rate (SGR) formula
- Extended the Medicare Cap exceptions process to December 31, 2017
- Began policy changes towards other significant Medicare reforms
Merit-Based Incentive Payment System (MIPS)
Providers have to enter data about their outcomes
- PT’s are currently not required to do this but its encouraged
What is the therapy cap amount?
$1,980 for PT and SLP combined
If a PT d/c a pt when they hit the cap, what is it considered?
Pt Abandonment
How does CMS decide which therapy services to review?
- Providers w/a pattern of irregular billing practices in comparison to their peers
- Providers w/a high percentage of claims denials or not compliant w/Medicare requirements
- Newly enrolled providers
2016 Comprehensive Care Joint Replacement Model
For elective hip & knee replacements → Sees if there’s a better way of doing things
- Hospitals receive a bundled payment for the episode of care
