Billing and Reimbursement

Question 1

Hospital Insurance

Answer 1

• 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

Question 2

Medical Insurance

Answer 2

• For those with Medicare part A
• Supplemental insurance for medically necessary outpatient services
• Some therapy in SNF and HH covered

Question 3

Medicare Advantage Plan

Answer 3

• 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

Question 4

Prescription Drug Coverage

Answer 4

• 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

Question 5

Medigap

Answer 5

Supplemental Plan to bridge the gap to help pay for out of pocket
medical expenses

Question 6

Early Intervention and Schools

Answer 6

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)

Question 7

Skilled Occupational Therapy

Answer 7

• Originated in Medicare regulation
• Skilled services-performed by qualified professionals
• Non-skilled services-routine or maintenance (caregivers, CNAs,
  RNAs, family members)

Question 8

Rehabilitative Therapy

Answer 8

• 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

Question 9

Rehabilitation: Documentation

Answer 9

must be:
* Objective
* Measurable
* Describes the skilled interventions implemented
* Clearly indicates any progress

Question 10

Skilled Maintenance Programs

Answer 10

-required to maintain the patient’s
current function or to prevent or slow further deterioration

Question 11

Maintenance Programs

Answer 11

• 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

Question 12

Safety Concerns

Answer 12

-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

Question 13

Prevention of Secondary Complications

Answer 13

Prevention of repetitive strain injuries, joint contractures, fracture nonunion, and skin breakdown/pressure sores

Question 14

Justification for Skilled Therapy

Answer 14

• Never embellish or fabricate information to substantiate
  treatment.
• Describe the skilled services provided to clients vs. Simply noting
  the client was assisted

Question 15

Timed and Untimed Services

Answer 15

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

Question 16

Therapy Students

Answer 16

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

Question 17

Durable Medical Equipment Criteria

Answer 17

• Can withstand repeated use
• Is primarily used to serve a medical purpose
• Is appropriate for use in the home

Question 18

CMS Examples of Fraud

Answer 18

• 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

Question 19

CMS Examples of Abuse

Answer 19

• 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