Exam 2 (wk 5-8) Flashcards
Chapters 30, 63, 12, 14, 27, 48, 29, 7, 46
Affordable Care Act (ACA)
Obamacare
U.S. federal statute
ACA marketplace exchanges
organizations created to allow individuals to compare and purchase private health insurance plans and facilitate access to tax credits that make those plans more affordable
in 2016, private health insurance accounted for
67.5% of coverage
most common subtype of private health insurance
employer-sponsored insurance
out-of-pocket expense
clients’ monthly payment to access insurance plan
deductible
set amount of money that a client must pay out of pocket each year prior to being authorized to obtain services at no or lower cost under the plan
copayment
set amount of money client must pay for each health care practitioner visit
coinsurance
money that a client is required to pay for services and is often specified by a percentage
ex: client pays 20% toward service charges and insurance pays 80%
coverage policies
contract between the health insurance company and and the policyholder (individual, group, organization) that delineates covered and non-covered services
covered healthcare services
services paid for in full under insurance policy
non-covered healthcare services
services not paid for in full under policy
indemnity
allow clients to visit almost any doctor or hospital they prefer
insurance then pays a set portion of the total charges
indemnity plans are also known as
fee-for-service plans
health benefits
a condition of employment after Taft-Harley Act
subject to bargaining
healthcare products and services that are covered in whole or part by a health plan
self-funded group health plans
aka self-insured plan
a health care benefit plan where the employer is responsible for paying most of the health bills, not just the insurance premiums
managed care
a continuum of arrangements that integrate the financing and delivery of healthcare
health maintenance organizations (HMOs)
pays for medical care only within their network of care providers
less cost
preferred provider organizations (PPOs)
covers more medical cost if patient receives care within network of providers
still pays some outside the network
point of service (POS)
patients can choose between PPO and HMO with each visit
exclusive provider organization (EPO)
services are only covered if patients go to doctors, hospitals, and specialists within the network (except in emergencies)
limited coverage with doctors, specialists or hospitals in the plan’s network
healthcare payment learning and action network (LAN)
Help advance the work being done across private, public, and nonprofit sectors to increase the adoption of value-based payments and additional new, innovative payment and care delivery models, often called alternative payment models
private employment-based group health plans are regulated by
U.S. Department of Labor
nonfederal government health plans are regulated by
U.S. Department of Health and Human Services
in-network
health care providers contracted into a health plans
out-of-network
providers who are not contracted or excluded from health plans
key questions to ask about coverage
Definition of OT
Limitations (visits, sites, costs)
Network of providers
Case management
Fee-for-service or bundle
Credentials for OT
Subscriber responsibility (copayment, deductible, other out-of-pocket)
billing responsibilities for OT managers
- Understand different coverage limitations, billing procedures, documentation requirements, and authorization processes, which may vary by payer
- Be aware of how OT services are regulated by the state(s) in which they practice, or in which the practitioners they oversee are practicing
- Teach and educate direct reports on how to submit charges and properly bill for services
- Create departmental policies and procedures, according to relevant laws, regulations, policies and rules
- Understand penalties clinicians can face for not properly billing for services and consequences they can face due to fraud and abuse
- Seek advice, education, consultation or services from billing experts, when needed
billing responsibilities for OTs
- Understand different coverage limitations, billing procedures, documentation requirements, and authorization processes, which may vary by payer
- Understand penalties clinicians can face for not properly billing for services and consequences they can face due to fraud and abuse
- “Occupational therapy practitioners cannot ignore the increasing number and complexity of laws,
regulations, and other rules that govern federal reimbursement and other health care programs….all face increased scrutiny in what they do and how they bill for it ”
penalties clinicians can face for not properly billing for services and consequences they can face due to fraud and abuse
Lose license
Barred for life from billing Medicare
Incur large fines
Go to jail
Criminal and civil liability
HHS, DOJ, OIG, formed
Health Care Fraud Prevention and Enforcement Action Team (HEAT) in high fraud cities
funded by the Omnibus Appropriations Act
False Claims Act
federal law that protects the government from fraud and abuse
makes it illegal to:
1. Knowingly submit false claims to the government
2. Cause someone to submit false claims to the government
3. Knowingly use false record material to a false claim
4. Improperly avoid an obligation to pay the government
Medicare fraud
knowingly submitting false claims or making misinterpretations of fact to obtain payment
knowingly soliciting, offering, receiving, or paying remuneration to induce reward referrals for items or services reimbursed by federal healthcare
making prohibited referrals for certain healthcare services
Medicare abuse
practices that directly or indirectly result in necessary cost to Medicare
Anti-Kickback Statute
limit influence of financial incentives on healthcare
makes it a criminal offense to knowingly or willingly offer, pay, solicit, or receive any payment to induce or reward referrals of items or services reimbursable by a federal healthcare program
Stark Law
prohibits providers from referring Medicare patients for certain “Designated Health Services” to an entity with which the physician has a relationship
prevents physicians from benefitting from their referrals
Civil Monetary Penalty Law
authorizes the imposition of substantial civil penalties or very large fines against entities who engage in prohibited activities
False Claims Act
“whistleblower law”
imposes liability on anyone who knowingly submits false claims to the government
HIPAA
Health Insurance Portability and Accountability Act
a federal law that protects patients’ health information and establishes standards for electronic health information
current procedural terminology
billing code system used by the healthcare industry
numerical codes assigned to each intervention or treatment, referred to as “procedure code”
help insurers determine amount of reimbursement for a given service
billed individually, separately or as a group or “bundled” billing codes
National Correct Coding Initiative
limits which codes can be billed together for the
same patient
Upcoding
billing for codes that reimburse at a higher rate instead of services
actually provided
Unbundling
billing for codes separately instead of as a group
safe harbors
allowable business arrangements that would escape prosecution under AKS
marketing
the process of identifying a set of strategies to communicate with potential consumers to attract and
persuade them to use your services
objectives of marketing
Meet the objectives of the company aligned to mission, vision and strategic plan priorities; social, managerial, financial, and operational objectives
Identifying and meeting customer needs
Creating awareness of the service/ product and increasing access
Develop standards and policies that ensure the quality of services
Promote goodwill
Build consumer loyalty, ensure value and satisfaction
target market
a specific group of consumers or clients at whom a company aims its products and services
3 primary target markets
- Clients and potential clients
- Payers
- Referral sources (Social media “influencer”)
niche market
Subset of the market in which services
or products are focused
Example:
Market = seniors
Niche Market = seniors with hip
replacement
Product = reachers
marketing mix/promotional mix
the tactical, controllable, and operational components of a marketing plan that may be combined to produce
the desired response form the target market
7 P’s of marketing mix
product
price
place
promotion
people
process
physical evidence
product
tangible (physical item), intangible (services)
must fill a need
appeal to a target market
have apparent value and purpose
advantage over existing/similar
price
money charged for a product or service
influenced by overhead costs
may be predetermined by governing bodies or third-party payers
place
physical or virtual location
how clients contact you
promotion
communication to potential customers about products/services
create consumer awareness
use multiple marketing promotions
advertising, sales promotion, public relations,
personal selling (most effective, least effective)
people
the company’s employees are important for marketing your product/service – they represent the company
process
how the service is delivered, essential for delivering
consistent quality of care and experience to foster
customer loyalty
physical evidence/environment
client’s impressions
what does your potential customer think the first time he/she encounters your product/service? (website,
entrance to the facility)
market analysis/research
gathering, organizing and analyzing information
organizational (SWOT) and environmental assessments
sociocultural trends
demographic
economic
political and regulatory issues
new technologies
planning
development of the marketing plan, activities and
strategies
has many components of your business plan –
gather information about the company, develop objectives and strategies
short and long term goals
implementation
process of executing or carrying out the marketing plan or “marketing campaign”
people and customer experience
everyplace
exchange
evangelism or “word-of-mouth” and
“testimonials”
monitoring
assessment of marketing strategies
enables redirection and adjustments to
plan
components of marketing plan
Description of products or services “elevator speech”
Mission statement
Vision statement
Description of the target market
Positioning strategy and unique selling proposition
Online marketing strategy
Advertising and promotional strategy
Sales and conversion strategy
Referral and retention strategy
Key performance indicators (KPIs)
Goals (SMART)
outcome marketing
focuses on results (beyond measuring metrics)
creating a personalized and engaging relationship through the customer’s experience with product or
service
comparing the results of your marketing plan with intended or projected results
growth opportunity frameworks
- Selling more current products to current customers
- Selling new products to current customers
- Selling more current products to new customers
- Selling new products to new customers
clients and potential clients
ex: adult patients recovering from an acute injury
payers
ex: commercial health insurance and federal programs
referral sources
ex: pediatrician
market position
defining an organizations unique selling proposition or how its services are unique
target marketing
allows you to reach, create awareness in, and influence the group of people most likely to select your products and services to solve their needs
steps to marketing management
analysis
planning
implementation
monitoring
organizational assessment
self-assessment of an organization’s strengths, weaknesses, opportunities, and threats
environmental assessment
greater forces, challenges, and trends in the environment that affect business relationships
needs assessment
A systematic approach used to identify gaps between current practices and desired practice conditions to determine a course of corrective action
considerations for starting a new program
understanding systems for inclusion and success
understand management in OT
understand budgeting
plan for growth
build managerial skills
networking
accreditaion orgnaizations
1)Utilization Review Accreditation Commission;
2) National Committee for Quality Assurance (NCQA);
3) The Joint Commission (TJC);
4) Commission on Accreditation of Rehabilitation Facilities (CARF)*
5) Council on Accreditation
program development
conceptualizing, formulating, starting, improving upon, or expanding educational, service delivery, or managerial-oriented work plans
program proposal
initial is brief 1 page to get attention
needs assessment outcome
business plan sections
background
ownership
market factors
market analysis
marketing
staffing
facilities
finances
consulting
The interactive process of helping others solve existing or potential problems by identifying and analyzing issues, developing strategies to
address problems, and preventing future problems from occurring
consultation stages
Initiation and clarification
Assessment and planning
Interactive problem resolution
Evaluation and termination
initiating consultation services
- Recognition of a problem may come from within the
organization, initiating a referral - Alternatively, consultant may recognize a problem and present a proposal
- Contract is developed
assessment and planning consultation
- Diagnostic analysis leading to problem identification
- Goal setting and planning through establishment of trust
interactive problem resolution
- Participative decision making with the client
- Consultant presents strategies
- Client decides which strategy to implement
eval and termination
- Consultant monitors strategy progress and addresses new issues that may result from the strategy that was implemented
- Formal evaluation performed
- Services discontinued
skills for consultants
communication
education
diagnosing
linking
relationships
attitudes
business plan-background
service environment, problem to be addressed
business plan-ownership
what expertise is there to run a program?
business plan-market factors
potential changes in the healthcare market
business plan-market analysis
SWOT analysis, potential customers, competitors, description of services to be offered
business plan-marketing
promotion and marketing strategies
business plan-staffing
needs for staff depend on client acuity, type and frequency of services, staff mix, and non productive time
business plan-facilities
what kind of building do you need?
business plan-equipment
wish list and needs list
business plan-finances
incomes and expenses
start-up costs
expenses incurred before the busines is open
(remodeling, decorating, insurance, rent, phone, licenses, equipment)
direct expenses
Expenses associated with the provision of services
(labor & materials)
indirect expenses
rent, electricity, phone
fixed costs
do not change with business
ex: rent
variable costs
expenses vary as business increases/decreases (e.g.,
splinting material)
breakeven point
revenue=expenditures
above breakeven point
profit
below breakeven point
loss
benefits of measuring healthcare outcomes
learning
improved performance
demonstration of superior outcomes
preparation for value-based payment
quality
defined as the degree to which healthcare services lead to desired health outcomes
5 quality healthcare measures
structural
process
outcome
patient experience
composite
structural quality
quality measurement via providers capacity, systems, and process
process quality
how providers specifically improve outcomes
outcomes quality
impact services have on patient health status
patient experience quality
patient perspectives on care
composite quality
comprehensive view of care
gross domestic product
total value of goods produced and services provided by a country in one year
percent of GDP spent on healthcare
17.8
value-based care
term that Medicare, doctors and other health care professionals sometimes use to describe health care that is designed to focus on quality of care, provider performance and the patient experience
volume-based care
fee-for-service care, is a payment model where providers are reimbursed depending on how many services or procedures they provide
a study done in 2016 said OT did what to hospital readmission rates?
OT is the only spending category to result in significantly lower readmissions rates
quadruple aim
adds provider experience to triple aim framework of improving experience, health of the population, and reducing per capita costs
process performance measure
whether a best practice was implemented by a practitioner
outcome performance measure
identify and quantify the results of healthcare services that clients achieve
emerging practice area
areas in which the occupational therapy role has not been established
traditional business plan
detailed and comprehensive
lenders and investors will request this type when an OT is seeking financing
executive summary, company description, market analysis, structure, services/product, marketing, funding, financial projections
lean start-up plan
highly focused and quick to write
lenders may not accept, but good to conceptualize emerging practice business
visual representation
business model canvas
business model canvas
key partners, activities, resources
value propositions
customer relationships
customer segments
channels
cost structure
revenue streams
CARE
Continuity Assessment Record and Evaluation
standardized assessment tool designed to capture patient data across different healthcare settings, such as acute care hospitals, inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies
CMS’ goal when developing CARE
standardized assessment
quality measurement
functioning of care coordination
payment reform
