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Intro To PT > Chapter 11 > Flashcards

Chapter 11 Flashcards

1
Q

Reimburesement

A

-payment of funds by a patient or an insurer to a healthcare provider for services rendered.

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2
Q

First party

A

patient

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3
Q

Second party

A

-physical therapist

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4
Q

third party

A

insurer

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5
Q

Insurer

A

-payer that makes payment services under the insurance coverage policy.

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6
Q

Capitation

A

-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

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7
Q

Fee-for service payment

A

-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.

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8
Q

The current healthcare market has caused insurance companies to reimburse only?

A

-a percentage of the total bill

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9
Q

Managed care

A

-a variety of methods of financing and organizing the delivery of health care in which costs are contained.

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10
Q

Health maintenance organization (HMO)

A

A type of health insurance plan that limits coverage to care from doctors who work for or contract with HMO.

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11
Q

Preferred provider organization (PPO)

A

similar to HMO
-however, it allows patients to choose out-of-network providers, but will not pay for 100% of those charges

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12
Q

Copayment

A

a amount to be paid by the patient to healthcare professionals each time a service is provided.

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13
Q

Deductibles

A

-portions of healthcare costs that the patient must pay prior to getting benefits from the insurance company.

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14
Q

EX of deductible of $1,000

A

patient pays the first $1,000 of healthcare costs and the insurance company will then assist with the healthcare bills.

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15
Q

Denial

A

-refusal by an insurer to reimburse for services that have been rendered
-TERM HATED BY HEALTHCARE PROFESSIONALS

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16
Q

Eligibility

A

-process of determining whether a patient qualifies for benefits, based on factors such as enrollment date, preexisting conditions, and valid referrals

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17
Q

Prior authorization

A

-required by some healthcare insurers that requires the patient or the healthcare provider to contact them to approve procedures or health care.

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18
Q

National Provider Identification (NPI)

A

-Unique # that identifies who individual healthcare providers and healthcare organizations are when performing such activities as billing.

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19
Q

Who has an NPI?

A

-only PTs
-PTA billing is coded using their supervising PTs NPI.

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20
Q

ICD-10-CM:
International Classification of Diseases, tenth revision, Clinical Modification

A

-these codes create a standardized classification of diagnoses across all health care settings and providers.

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21
Q

ICD-10-CM codes…

A

-diagnoses
-symptoms
-inpatient procedures

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22
Q

CPT:
Current procedural terminology

A

-a list of descriptive terms that contains fiver-character, numeric codes assigned to nearly every healthcare service.
-every billing needs a CPT

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23
Q

Who creates CPT?

A

American Medical Association

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24
Q

Which range does physical therapy providers utilize the procedural codes?

A

-97000 range

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25
Q

97000 codes are considered…

A

-TIMED CODES
-it is important to record the exact number of minutes the procedure was performed

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26
Q

Billing is done in..

A

-units
-each unit is 15 minute period of time

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27
Q

Medicare billing

A

-the number of units billed will be based on the 8 minute rule

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28
Q

8 minute rule

A

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

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29
Q

untimed CPT codes

A

-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.

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30
Q

Who can reimburse physical therapy services?

A

-Medicare
-Medicaid
-private health insurance companies
-HMOs

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31
Q

Medicare

A

-largest provider of healthcare services in the U.S.
-established in 1965

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32
Q

Medicare is a health insurance program for the following persons..

A

-people 65 and up
-people younger than 65 with certain disabilities
-people of all kinds of ages with end-stage renal disease

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33
Q

who administers the Medicare program and Medicaid?

A

-centers for medicare and medicaid services

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34
Q

what is the purpose of the CMS?

A

-developed quality strategies to assist the agency in:
improving patient care,
containing healthcare costs,

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35
Q

4 parts of medicare

A

-Part A
-Part B
-Part C
-Part D

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36
Q

Part A

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

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37
Q

Part B

A

-medical insurance
-monthly premium paid

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38
Q

Part B helps cover

A

-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

39
Q

Part C

A

-Medicare advantage
-includes health plans offered by private companies and approved by Medicare.
-pay additional monthly premiums.

40
Q

Part D

A

-Medicare prescription drug coverage
-available to everyone with Medicare, but involves additional costs.

41
Q

Prospective payment system (PPS)

A

-fixed payment that is matched to diagnosis classifications known as diagnosis-related groups in acute care setting.

42
Q

Medicare and SNF

A

-is paid for through Part A or Part B
-each patient entering SNF receives an assessment known as minimum data set

43
Q

Minimum data set

A

-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.

44
Q

Patient Driven Payment Model

A

-new payment system
-will look at individual residents in the SNF and score them in each 5 categories.

45
Q

5 categories of (PDPM)

A

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)

46
Q

SNF will be reimbursed for residents on Medicare part A based upon?

A

-residents case mix components during their qualified stay in the SNF.

47
Q

Inpatient rehab payment system

A

-similar to SNF
-patient is assessed using inpatient rehab assessment to classify the patient and identify the predetermined payment amount.

48
Q

Outcome and Assessment information set

A

-an assessment tool utilized for home health care.
-tool shows patient improvement overtime and is also used to classify the patient for payment groups.

49
Q

What else predetermines payment?

A

-services being provided to patients with multiple health problems.
-adjusts the amount of payment based on geographic location.

50
Q

Bipartisan Budget Act of 2018

A

-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

51
Q

Soft cap

A

-combines physical therapy and speech therapy services and has a separate dollar amount of occupational services. $2,040

52
Q

KX billing code

A

-if patient exceeds dollar amount in soft cap, provider can apply KX to indicate medical necessity for continued services.

53
Q

KX billing code allows for continued services up to$?

A

-$3,000
-before a medical review takes place to confirm necessity of provided services.

54
Q

Who is subject to quality payment program?

A

-services provided in clinics not associated with SNFs, hospitals, and rehab facilities.

55
Q

Two programs of quality payment program

A

1)Merit based incentive payment system
2)advanced alternative payment models

56
Q

Goal of each system

A

-aims to moving away from fee-for-service and toward payment for quality service.

57
Q

Within each system PTs…

A

-are required to submit info. related to patients outcome measures and other standards of quality services.
-submitted data creates rating for PT.

58
Q

Pts with high percentage ratings=

A

-receive bonus payment from CMS

59
Q

PTS with medium percentage ratings

A

-will receive neither incentives or penitlites.P

60
Q

PTS will low percentage ratings=

A

-receive penitlities

61
Q

Are PTAs considered MIPs eligible?

A

-No, but the can bill utilizing the PTs NPI and affect their PTs MIP rating.

62
Q

Medicaid

A

-enacted in 1965
-jointly funded program in which the federal government matched state spending to provide medical and health related services.

63
Q

Who are Medicaid services designed for?

A

-children
-nonelderly low income parents
-caretaker relatives
-pregnant women
-nonelderly individuals with disabilities
-low income elderly people

64
Q

What service may be optional and is determined under state-by-state basis?

A

-pt services

65
Q

State regulations of Medicaid and physical therapy

A

-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.

66
Q

Affordable Healthcare Act

A

-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

67
Q

Private insurance companies

A

-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

68
Q

EX of private insurance companies

A

-Blue Cross Blue Shield
-Humana
-Coventry

69
Q

Physical therapy model benefit plan design

A

-created by APTA as a resource to help insurance companies understand the purpose and benefits of physical therapy to their policyholders.

70
Q

HMO: Health Maintenance Organization

A

-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.

71
Q

4 groups of HMOs

A

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

72
Q

Tricare

A

-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

73
Q

Veterans Health Administration System

A

-healthcare system for active and retired active military personnel who qualify

74
Q

Importance of research in physical therapy

A

-determines effectiveness of lack of effectiveness of various physical therapy services for patients/clients.
-goal is to improve patient care

75
Q

QI (Quality improvement): research performed by PT/PTA

A

-practice that measures a specific practice quality, implements practice changes, and monitors outcomes to determine the effect.

76
Q

EX of QI issue

A

-monitoring how many days the average patient with a total knee arthroplasty remains in acute care and what factors accelerate or slow the discharge

77
Q

Types of research activities done by PTA/PT

A

-QI
-asking a specific question about their practice
-staying informed

78
Q

How can searches be improved?

A

-use of PICO format
-placing quotation marks
-using the word AND or OR

79
Q

Level of evidence

A

-degree of confidence that the reader can place in the research, based upon study design.
-PRYAMID

80
Q

Systemic reviews

A

-created by systemically searching for, evaluating, and summarizing all medical research pertaining to particular topic.

81
Q

Metanaylsis

A

-allows for individual studies to be combined to produce more significant findings.

82
Q

Reliability in research

A

-the ability of the research activity to show the same results when repeated by another researcher

83
Q

Randomized controlled trails

A

-test subjects placed into two groups
1) experimental group (gets treatment)
2) control group (baseline group)

84
Q

Observational studies

A

-include cohort studies and case-control studies

85
Q

Case studies

A

-investigations of a single individual or group for which the researcher provides an in depth description of their disorder, interventions, and outcomes.

86
Q

Elements of research study

A

-title and abstract
-introduction
-methods
-results
-discussion and conclusion

87
Q

Title and abstract

A

-should be informative
-reader should be interested in topic after reading title/abstract

88
Q

Introduction

A

-should distinguish previous research and current study
-hypothesis, type of study, specific purpose.

89
Q

Methods

A

-info on subjects, study design, equipment, research procedures, issues of validity, data analysis.

90
Q

Validity

A

-how meaningful test scores are as they are used for specific purposes

91
Q

Alpha level

A

-probability of concluding that the null hypothesis is false (when in fact it is true).

92
Q

alpha level as a probability

A

-set between 0.05 and 0.01.
-the lower the alpha level the better the experiment

93
Q

What does alpha level of 0.05 mean?

A

-the statistical results of the experiment can happen 5 times out of every 100.

Intro To PT (25 decks)

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