Billing and Reimbursement Flashcards
Hospital Insurance
- Covers inpatient hospital care, limited SNF stays, hospice, and home health.
- Premiums are generally free if enough Medicare taxes paid
- Deductibles and other expenses may apply
Medical Insurance
- For those with Medicare part A
- Supplemental insurance for medically necessary outpatient services
- Some therapy in SNF and HH covered
Medicare Advantage Plan
- Plan contracted with private insurance companies (HMO, PPO) to provide Medicare Parts A & B benefits.
- Variety of plans for comparison
- Cost of premiums vary depending on the plan
- Usually include some coverage for prescription medications
Prescription Drug Coverage
- Coverage through Medicare-approved companies
- Cost of premiums and out-of-pocket expenses vary between plans
- Individuals with parts Medicare A & B can purchase a Medicare Part D plan
Medigap
Supplemental Plan to bridge the gap to help pay for out of pocket
medical expenses
Early Intervention and Schools
IDEA covers early intervention (EI) services for children under 3 years
* Medicaid or private insurance plans also cover EI services
* Part B of IDEA pertains to children ages 3-21
* Medicaid reimburses for medically necessary direct services (OT)
Skilled Occupational Therapy
- Originated in Medicare regulation
- Skilled services-performed by qualified professionals
- Non-skilled services-routine or maintenance (caregivers, CNAs,
RNAs, family members)
Rehabilitative Therapy
- Are the skills of a therapist truly needed?
- A chronic condition does not negate the need for OT if the client’s function could reasonably improve(occupations!!!)
- OT must document how what we do is different from that of other disciplines
Rehabilitation: Documentation
must be:
* Objective
* Measurable
* Describes the skilled interventions implemented
* Clearly indicates any progress
Skilled Maintenance Programs
-required to maintain the patient’s
current function or to prevent or slow further deterioration
Maintenance Programs
- Help clients maintain present function or slow down/prevent further deterioration
- Skilled therapy may be used to design and establish such programs
- Periodic reassessments are covered
- Typically 1-2 sessions
Safety Concerns
-Interventions targeting safety are typically covered by insurance
because they prevent costly injury -include fall risk, decreased environmental awareness, severe pain, absent skin sensation, maladaptive
behaviors, suicide risk
Prevention of Secondary Complications
Prevention of repetitive strain injuries, joint contractures, fracture nonunion, and skin breakdown/pressure sores
Justification for Skilled Therapy
- Never embellish or fabricate information to substantiate
treatment. - Describe the skilled services provided to clients vs. Simply noting
the client was assisted
Timed and Untimed Services
Many CPT codes are based on time using 15-minute intervals but can be
8- 22 minutes (8-minute rule)
* Untimed procedures are billed at a fixed amount
Therapy Students
Strict criteria must be followed for billing of Medicare part B services:
* The qualified practitioner supervising the student must be present in
the room,
* responsible for the services, and
* not performing other tasks or treating other clients at the same time
Durable Medical Equipment Criteria
- Can withstand repeated use
- Is primarily used to serve a medical purpose
- Is appropriate for use in the home
CMS Examples of Fraud
- Billing for services that were not provided
- Billing for missed client appointments
- Paying or receiving bribes or kickbacks for client referrals
- Misrepresenting a service as a covered service when it is not
- Duplicate billing to obtain more than the allowable amount
CMS Examples of Abuse
- Billing excessive charges for services
- Providing and billing for services that are not medically necessary
- Providing services that do not meet recognized standards of
professional care - Billing Medicare using a higher fee schedule than the one used
for non-Medicare clients
