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