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3) Health Care Delivery 1 > 5) Medicare > Flashcards

5) Medicare Flashcards

1
Q

Center for Medicare and Medicaid (CMS)

A

Part of the executive branch, which promulgates regulations

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2
Q

What are MAC’s?

A

They’re the ones who actually do the billing, reimbursements, etc

  • The way they interpret the law can sometimes be problematic
  • Local govt
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3
Q

MedPAC

A

Advisory group to Congress

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4
Q

What individuals under the age of 65 can get Medicare coverage?

A
  • Permanently disabled
  • Have end-stage renal disease
  • Have ALS
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5
Q

Where do most Medicare pt’s live?

A

At home

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6
Q

Why does Medicare have high cost-sharing responsibilities and what does this mean for Medicare households?

A

There’s limit to out-of-pocket pay so households tend to have high spending patterns

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7
Q

What is a pro and con Medicare Part C (Medicare Advantage)?

A
  • Pro = Less expensive
  • Con = Restrictive to pt’s
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8
Q

True or False: Its illegal for Medicare to pay a provider if they don’t submit the proper documentation

A

True

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9
Q

What do providers need to submit to Medicare in order to get reimbursed?

A

Claims Form

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10
Q

Explain how Medicare provider payment works

A

They pre-determine a base payment for a given service and then make adjusts based on variables such as:

  • Geographic location
  • Pt complexity
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11
Q

Explain Medicare payments for acute care hospitals

A
  • 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
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12
Q

How are IRF’s paid?

A

Based on a pt case mix

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13
Q

CMS 60% Rule

A

Facility needs to prove that at least 60% of admissions meet the qualifying conditions

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14
Q

Explain SNF payment

A
  • 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
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15
Q

What 4 criterion need to be met in order for Medicare to pay for care received in an SNF?

A

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

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16
Q

How many minutes of rehab are needed for each RUG classification?

A
  • 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
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17
Q

What are the rules to have Medicare Part A cover home health?

A
  • 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
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18
Q

What is used to assign a pt to a home health resource group?

A

The OASIS

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19
Q

How long is the basic unit of payment for home health?

A

60 days

20
Q

What can cause the home health case rate to change and what occurs as a result?

A
  • Pt reaches goals → Partial episode payment
  • Pt change from initial POC → “Significant change in condition”adjustment
21
Q

When can Medicare Part B be used for home health?

A
  • When 100 day Part A benefit expires
  • 3-day hospital stay requirement not met
22
Q

Describe Medicare Hospice Payment

A
  • 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
23
Q

How is payment decided for outpatient providers?

A

Based on a Medicare Fee Schedule

24
Q

What 3 settings make up the majority of utilized outpatient services?

A

1) Private Practice
2) SNF
3) Hospital OP

25
Q

Resource-Based Relative Value Scale (RBRVS)

A

Price of services should be based on the cost associated w/providing that service

  • Basis for outpatient payment
26
Q

For PT services, who determines medical necessity and how do they do this?

A

The evaluating PT → Through clear evidence in documentation

27
Q

What makes something a “skilled service”?

A

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
28
Q

What happens a pt is judged safe and the skill of a PT and services are no longer necessary or reasonable?

A

You can no longer bill for services bc its not skilled care

29
Q

Can you bill for care by an aide?

A

No

30
Q

Can you bill for an independent activity?

A

No

31
Q

Can you bill for the performance of a mastered task?

A

No

32
Q

Can you bill for a continued repetitive maintenance program and why?

A

No → Need to have some variation

33
Q

Certification

A

Physician’s/NPP approval of the POC

  • Dated signature
34
Q

Non-Physician Practitioner (NPP)

A

PA, clinical nurse specialist, or nurse practitioner who may certify if permitted by state and local laws

35
Q

Who is considered a qualified professional and what does this mean?

A

PT, OP, SLP, NP, CNS, MD, PA → They can bill for therapeutic services

36
Q

Define Orders/Referrals/Need for Care and describe its role in payment.

A

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
37
Q

At what point do POC’s need to be established?

A

Before tx begins

38
Q

Can eval and tx occur on the same day and be billable?

A

Yes

39
Q

What happens w/non-covered services?

A

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
40
Q

Explain billing Medicare for care administered by a PTA

A
  • Billable
  • Must be supervised a PT (or follow state practice act)
  • Anything outside of PTA’s scope of practice is not billable
41
Q

Can an HCP get a Therapy Cap exception? If so, what’s the process?

A
  • Use a KX modifier
  • Clinician can show medical necessity
  • Beneficiary must meet other requirements for therapy
42
Q

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

A
  • 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
43
Q

Merit-Based Incentive Payment System (MIPS)

A

Providers have to enter data about their outcomes

  • PT’s are currently not required to do this but its encouraged
44
Q

What is the therapy cap amount?

A

$1,980 for PT and SLP combined

45
Q

If a PT d/c a pt when they hit the cap, what is it considered?

A

Pt Abandonment

46
Q

How does CMS decide which therapy services to review?

A
  • 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
47
Q

2016 Comprehensive Care Joint Replacement Model

A

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

3) Health Care Delivery 1 (13 decks)

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