Block 5 Flashcards
Part A
Part B
Part A: hospital insurance
Part B: medical insurance or supplemental insurance
Part C
run by private insurers- medicare advantage
Part D
Drug benefit added
FFS medicare
Fee for service- typical or traditional medicare
Medicare offers important coverage but with _____ cost sharing and benefits ____-
high cost sharing and benefit gaps
no limit on out of pocket spending
no dental, hearing aids or eyeglasses
To get dental, hearing aids or glasses what do they need to do
get supplemental insurance plan
What is the incentive in a fee for service payment model
financial incentives that providers take advantage
encourages more service
more expensive services
rewards proceduralists
Does not encourage prevention
Part A: hospital insurance
no premiums unless pt or spouse has not worked 40 or more quarters in their life
primary payer for
-acute care
-SNF
-home health
-IRF
Part A covers ____days for _____
part A covers 60 days in acute care hospitals, inpatient rehab facilities. and long term acute care
What is the prospective payment system that replaced fee for service in medicare
payment of a set amount to the provider/institution for each admission episode
What is Diagnosis related group
a type of pps
classifieds acute hospital cases into one of 500 groups based on ICD-10 diagnosis and determine payment level
Pt with DRG are clinically similar
what is the incentive of a DRG
incentive for hospital to make a quick d/c minimize costly care
What was the result of DRG
patient much sicker/more disabled upon discharge
Does medicare pay for custodial care facilities?
no medicaid does
Part A SNF coverage
day 1-20 must follow qualifying hospitizlation to be fully covered after 21-100 days patient pays about 200$ a day
to qualify for a SNF
need skilled nursing care on a daily bases
prior 3 consecutive days hospital stay
prior hospital stay transferred to SNF within 30 days
New model created in SNF from teh RUGs to ____
Patient drive payment model
Describe the patient driven payment model
switched from RUGs which was based on treatment mintues
Focused on multi-disciplinary
outcome driven
clinical complexity and medical diagnosis
What is inpatient rehab
clinically stable
able to tolerate at least 3 hours of rehab therapy at least 5x/week
75% rule
What is the 75% rule
focus on medical necessity and functional capacity
require that all inpatient rehab facilities have at least a certain % of their admissions fall into 13 diagnostic categories
as long as they meet the required % threshold IRFs can admit other patients with diagnosis not related
Did the 75% rule make it all the way?
no because they began worrying about access
so a minimum of 60% admission to IRF must meet criteria
Requirement for home health care
homebound
under care of physician
requires skilled care of nursing, physical, or speech
OASIS documentation
Part B: medical insurance or supplemental medical insurance
covers: physician
outpatient pt
ambulance services
lab testing
How does part B work
part b has premium based on income
deductible and co-insurance
Can we bill for a service provided by a PTA under medicare part B
NO
What is the 8 minute rule
1 unit 8-22
2 unit 23-37
3 units 38-52
4 units 53-67
bill for # of minutes of care
What is a modifier
a code used on medicare billing forms which indicates an important piece of information the provider needs to convey
What is the part B soft cap
pt gets a certain amount of coverage per year however if PT can document that the pt needs more therapy they need to ask for approval
Medicare direct access
a referral is not required but a plan of care must be signed and in the patients chart within a certain time period so need to get DO or MD to sign
Is dry needling covered by medicare
no
What is an advanced beneficiary notice
a notice provided by a health care provider which says medicare wont pay for a service
if you dont have this on file then you cant bill for it
Observation status
part B pays for it: instead of admission the patient is kept on observation status by hospital, no risk of readmission where hospital is penalized
almost ____% of people obtain supplemental coverage in addition to part A and B
80%
Examples of supplemental coverages
- traditional medigap plan
- employer sponsored- could be from a retirement benefit
- medicaid- supplement for the poor/disabled medicare advantage.part C
Part C
a health coverage choice run by private health companies approved by medicare
open enrollement except for those with end stage renal disease who must stay on regular medicare
Part D
drug coverage all privately run plans
paid for by medicare
subsidize the cost of prescription drugs for the medicare beneficiaries
