Block 5

Question 1

Part A
Part B

Answer 1

Part A: hospital insurance
Part B: medical insurance or supplemental insurance

Question 2

Part C

Answer 2

run by private insurers- medicare advantage

Question 3

Part D

Answer 3

Drug benefit added

Question 4

FFS medicare

Answer 4

Fee for service- typical or traditional medicare

Question 5

Medicare offers important coverage but with _____ cost sharing and benefits ____-

Answer 5

high cost sharing and benefit gaps

no limit on out of pocket spending
no dental, hearing aids or eyeglasses

Question 6

To get dental, hearing aids or glasses what do they need to do

Answer 6

get supplemental insurance plan

Question 7

What is the incentive in a fee for service payment model

Answer 7

financial incentives that providers take advantage
encourages more service
more expensive services
rewards proceduralists
Does not encourage prevention

Question 8

Part A: hospital insurance

Answer 8

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

Question 9

Part A covers ____days for _____

Answer 9

part A covers 60 days in acute care hospitals, inpatient rehab facilities. and long term acute care

Question 10

What is the prospective payment system that replaced fee for service in medicare

Answer 10

payment of a set amount to the provider/institution for each admission episode

Question 11

What is Diagnosis related group

Answer 11

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

Question 12

what is the incentive of a DRG

Answer 12

incentive for hospital to make a quick d/c minimize costly care

Question 13

What was the result of DRG

Answer 13

patient much sicker/more disabled upon discharge

Question 14

Does medicare pay for custodial care facilities?

Answer 14

no medicaid does

Question 15

Part A SNF coverage

Answer 15

day 1-20 must follow qualifying hospitizlation to be fully covered after 21-100 days patient pays about 200$ a day

Question 16

to qualify for a SNF

Answer 16

need skilled nursing care on a daily bases
prior 3 consecutive days hospital stay
prior hospital stay transferred to SNF within 30 days

Question 17

New model created in SNF from teh RUGs to ____

Answer 17

Patient drive payment model

Question 18

Describe the patient driven payment model

Answer 18

switched from RUGs which was based on treatment mintues

Focused on multi-disciplinary
outcome driven
clinical complexity and medical diagnosis

Question 19

What is inpatient rehab

Answer 19

clinically stable
able to tolerate at least 3 hours of rehab therapy at least 5x/week
75% rule

Question 20

What is the 75% rule

Answer 20

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

Question 21

Did the 75% rule make it all the way?

Answer 21

no because they began worrying about access
so a minimum of 60% admission to IRF must meet criteria

Question 22

Requirement for home health care

Answer 22

homebound
under care of physician
requires skilled care of nursing, physical, or speech
OASIS documentation

Question 23

Part B: medical insurance or supplemental medical insurance

Answer 23

covers: physician
outpatient pt
ambulance services
lab testing

Question 24

How does part B work

Answer 24

part b has premium based on income
deductible and co-insurance

Question 25

Can we bill for a service provided by a PTA under medicare part B

Answer 25

NO

Question 26

What is the 8 minute rule

Answer 26

1 unit 8-22
2 unit 23-37
3 units 38-52
4 units 53-67
bill for # of minutes of care

Question 27

What is a modifier

Answer 27

a code used on medicare billing forms which indicates an important piece of information the provider needs to convey

Question 28

What is the part B soft cap

Answer 28

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

Question 29

Medicare direct access

Answer 29

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

Question 30

Is dry needling covered by medicare

Answer 30

no

Question 31

What is an advanced beneficiary notice

Answer 31

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

Question 32

Observation status

Answer 32

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

Question 33

almost ____% of people obtain supplemental coverage in addition to part A and B

Answer 33

80%

Question 34

Examples of supplemental coverages

Answer 34

1. traditional medigap plan
2. employer sponsored- could be from a retirement benefit
3. medicaid- supplement for the poor/disabled medicare advantage.part C

Question 35

Part C

Answer 35

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

Question 36

Part D

Answer 36

drug coverage all privately run plans
paid for by medicare
subsidize the cost of prescription drugs for the medicare beneficiaries