Chapter 11 Flashcards
Reimburesement
-payment of funds by a patient or an insurer to a healthcare provider for services rendered.
First party
patient
Second party
-physical therapist
third party
insurer
Insurer
-payer that makes payment services under the insurance coverage policy.
Capitation
-a reimbursement method that pays the provider a fixed amount for each month, based on the number of patients enrolled in the insurance plan.
-MAINLY USED BY MANAGED CARE ORGANIZATIONS
Fee-for service payment
-payment for specific healthcare services that were provided to a patient.
-payment can be made by patient or insurance carrier.
-when a procedure is performed, a fee is charged, and the patient or insurance provider pays it.
The current healthcare market has caused insurance companies to reimburse only?
-a percentage of the total bill
Managed care
-a variety of methods of financing and organizing the delivery of health care in which costs are contained.
Health maintenance organization (HMO)
A type of health insurance plan that limits coverage to care from doctors who work for or contract with HMO.
Preferred provider organization (PPO)
similar to HMO
-however, it allows patients to choose out-of-network providers, but will not pay for 100% of those charges
Copayment
a amount to be paid by the patient to healthcare professionals each time a service is provided.
Deductibles
-portions of healthcare costs that the patient must pay prior to getting benefits from the insurance company.
EX of deductible of $1,000
patient pays the first $1,000 of healthcare costs and the insurance company will then assist with the healthcare bills.
Denial
-refusal by an insurer to reimburse for services that have been rendered
-TERM HATED BY HEALTHCARE PROFESSIONALS
Eligibility
-process of determining whether a patient qualifies for benefits, based on factors such as enrollment date, preexisting conditions, and valid referrals
Prior authorization
-required by some healthcare insurers that requires the patient or the healthcare provider to contact them to approve procedures or health care.
National Provider Identification (NPI)
-Unique # that identifies who individual healthcare providers and healthcare organizations are when performing such activities as billing.
Who has an NPI?
-only PTs
-PTA billing is coded using their supervising PTs NPI.
ICD-10-CM:
International Classification of Diseases, tenth revision, Clinical Modification
-these codes create a standardized classification of diagnoses across all health care settings and providers.
ICD-10-CM codes…
-diagnoses
-symptoms
-inpatient procedures
CPT:
Current procedural terminology
-a list of descriptive terms that contains fiver-character, numeric codes assigned to nearly every healthcare service.
-every billing needs a CPT
Who creates CPT?
American Medical Association
Which range does physical therapy providers utilize the procedural codes?
-97000 range
97000 codes are considered…
-TIMED CODES
-it is important to record the exact number of minutes the procedure was performed
Billing is done in..
-units
-each unit is 15 minute period of time
Medicare billing
-the number of units billed will be based on the 8 minute rule
8 minute rule
this rule states that timed code procedures must last at least 8 minutes in order to bill 1 unit.
-procedure that is 8-22 minutes is one unit
untimed CPT codes
-procedures that do not require constant supervision
-97012(mechanical traction).
-97014 (electrical stimulation)
-these are billed as one unit and do not fall under 8 minute rule.
Who can reimburse physical therapy services?
-Medicare
-Medicaid
-private health insurance companies
-HMOs
Medicare
-largest provider of healthcare services in the U.S.
-established in 1965
Medicare is a health insurance program for the following persons..
-people 65 and up
-people younger than 65 with certain disabilities
-people of all kinds of ages with end-stage renal disease
who administers the Medicare program and Medicaid?
-centers for medicare and medicaid services
what is the purpose of the CMS?
-developed quality strategies to assist the agency in:
improving patient care,
containing healthcare costs,
4 parts of medicare
-Part A
-Part B
-Part C
-Part D
Part A
-hospital insurance
-most people do not pay a premium for Part A because they or a spouse already pay for it through payroll taxes while working.
-SNF, home health, hospice, inpatient
Part B
-medical insurance
-monthly premium paid
Part B helps cover
-doctors services and outpatient care
-medically necessary services to diagnose or treat a medical condition
-Part A claims for patients whose claim limit has been denied.
-other medical services that part A does not cover
Part C
-Medicare advantage
-includes health plans offered by private companies and approved by Medicare.
-pay additional monthly premiums.
Part D
-Medicare prescription drug coverage
-available to everyone with Medicare, but involves additional costs.
Prospective payment system (PPS)
-fixed payment that is matched to diagnosis classifications known as diagnosis-related groups in acute care setting.
Medicare and SNF
-is paid for through Part A or Part B
-each patient entering SNF receives an assessment known as minimum data set
Minimum data set
-looks at functional skills, hearing, vision, cognitive skills, and so on.
-this info.is used to determine the amount of skilled care that the resident will require from the staff.
Patient Driven Payment Model
-new payment system
-will look at individual residents in the SNF and score them in each 5 categories.
5 categories of (PDPM)
1)physical therapy case mix
2)occupational therapy case mix
3)speech language pathology case mix
4)nursing case mix
5)non-ancillary case mix (relates to medications and medical supplies)
SNF will be reimbursed for residents on Medicare part A based upon?
-residents case mix components during their qualified stay in the SNF.
Inpatient rehab payment system
-similar to SNF
-patient is assessed using inpatient rehab assessment to classify the patient and identify the predetermined payment amount.
Outcome and Assessment information set
-an assessment tool utilized for home health care.
-tool shows patient improvement overtime and is also used to classify the patient for payment groups.
What else predetermines payment?
-services being provided to patients with multiple health problems.
-adjusts the amount of payment based on geographic location.
Bipartisan Budget Act of 2018
-changed medicare part B outpatient therapy services
-there was a cap on therapy services that would not allow greater then $2,010 to be billed from PT and speech, and $2010 for occupational services.
-this act removed this cap
Soft cap
-combines physical therapy and speech therapy services and has a separate dollar amount of occupational services. $2,040
KX billing code
-if patient exceeds dollar amount in soft cap, provider can apply KX to indicate medical necessity for continued services.
KX billing code allows for continued services up to$?
-$3,000
-before a medical review takes place to confirm necessity of provided services.
Who is subject to quality payment program?
-services provided in clinics not associated with SNFs, hospitals, and rehab facilities.
Two programs of quality payment program
1)Merit based incentive payment system
2)advanced alternative payment models
Goal of each system
-aims to moving away from fee-for-service and toward payment for quality service.
Within each system PTs…
-are required to submit info. related to patients outcome measures and other standards of quality services.
-submitted data creates rating for PT.
Pts with high percentage ratings=
-receive bonus payment from CMS
PTS with medium percentage ratings
-will receive neither incentives or penitlites.P
PTS will low percentage ratings=
-receive penitlities
Are PTAs considered MIPs eligible?
-No, but the can bill utilizing the PTs NPI and affect their PTs MIP rating.
Medicaid
-enacted in 1965
-jointly funded program in which the federal government matched state spending to provide medical and health related services.
Who are Medicaid services designed for?
-children
-nonelderly low income parents
-caretaker relatives
-pregnant women
-nonelderly individuals with disabilities
-low income elderly people
What service may be optional and is determined under state-by-state basis?
-pt services
State regulations of Medicaid and physical therapy
-some states do not allow PTAs to provide services to Medicaid patients in attempt to contain costs
-small premium or copayment for services must be paid by Medicaid enrollee.
Affordable Healthcare Act
-requires states expand services to Medicaid to provide coverage to nonelderly, nondisabled adults with incomes at or below 138% of federal poverty level.
-goal is to improve healthcare access
Private insurance companies
-provide health insurance to individuals and employees through employer provided plans.
-each plan has variety of benefits, require copayments, and may require authorization of services
EX of private insurance companies
-Blue Cross Blue Shield
-Humana
-Coventry
Physical therapy model benefit plan design
-created by APTA as a resource to help insurance companies understand the purpose and benefits of physical therapy to their policyholders.
HMO: Health Maintenance Organization
-form of managed care
-provides health services by a limited number of health care professionals for a fixed prepaid fee.
-a third party payer that directs patients to specific providers who have contracted with the managed care company.
4 groups of HMOs
1)Staff HMO- healthcare providers are employees of HMO, providing care only for HMO members
2) Group HMOs-healthcare is provided by a separate group of physicians having contracts with HMO to treat only HMO members
3)Individual practice Associations
4)Network HMOs- HMO has contract with a # of large physicians groups
Tricare
-health care program for members of the armed services and their family
-there is a rule to go into affect in 2020, that will allow PTAs to treat patients with Tricare
Veterans Health Administration System
-healthcare system for active and retired active military personnel who qualify
Importance of research in physical therapy
-determines effectiveness of lack of effectiveness of various physical therapy services for patients/clients.
-goal is to improve patient care
QI (Quality improvement): research performed by PT/PTA
-practice that measures a specific practice quality, implements practice changes, and monitors outcomes to determine the effect.
EX of QI issue
-monitoring how many days the average patient with a total knee arthroplasty remains in acute care and what factors accelerate or slow the discharge
Types of research activities done by PTA/PT
-QI
-asking a specific question about their practice
-staying informed
How can searches be improved?
-use of PICO format
-placing quotation marks
-using the word AND or OR
Level of evidence
-degree of confidence that the reader can place in the research, based upon study design.
-PRYAMID
Systemic reviews
-created by systemically searching for, evaluating, and summarizing all medical research pertaining to particular topic.
Metanaylsis
-allows for individual studies to be combined to produce more significant findings.
Reliability in research
-the ability of the research activity to show the same results when repeated by another researcher
Randomized controlled trails
-test subjects placed into two groups
1) experimental group (gets treatment)
2) control group (baseline group)
Observational studies
-include cohort studies and case-control studies
Case studies
-investigations of a single individual or group for which the researcher provides an in depth description of their disorder, interventions, and outcomes.
Elements of research study
-title and abstract
-introduction
-methods
-results
-discussion and conclusion
Title and abstract
-should be informative
-reader should be interested in topic after reading title/abstract
Introduction
-should distinguish previous research and current study
-hypothesis, type of study, specific purpose.
Methods
-info on subjects, study design, equipment, research procedures, issues of validity, data analysis.
Validity
-how meaningful test scores are as they are used for specific purposes
Alpha level
-probability of concluding that the null hypothesis is false (when in fact it is true).
alpha level as a probability
-set between 0.05 and 0.01.
-the lower the alpha level the better the experiment
What does alpha level of 0.05 mean?
-the statistical results of the experiment can happen 5 times out of every 100.
