FE Flashcards
3 Managed Care Principles
1) limited access to the universe of providers
2) payment mechanisms that reward efficiency
3) enhanced quality control procedures
Which of the 3 Managed Care Principles is described below:
-panel of health care providers that are contracted with or employed by the MCO
-Limiting the providers creates competition in areas of heavy MCO concentration
Panels can be opened or closed
- Panels go through a credentialing process that reviews:
- Authorization of services = often primary care physicians serve as gatekeepers
limited access to the universe of providers
Which of the 3 Managed Care Principles is described below:
- Providers are reimbursed for their services through a variety of ways.
- Provider assumes either some or all of the financial risk
payment mechanisms that reward efficiency
Which of the 3 Managed Care Principles is described below:
- MCOs perform utilization review, clinical pathways, benchmarking, and case management functions
- Case managers = coordinate all aspects of patient care
- Therapy benefit managers = intermediary between the patient/therapist and insurer/MCO. Evaluate the appropriateness of therapy. Employed by companies that contract with MCOs.
enhanced quality control procedures
What’s Discounted fee schedule?
providers accept a contract that is less than the full charge for certain services.
What’s Bundle Payment System ?
the insurer begins to limit financial risk. This is done by paying one fee to the provider for a set of patient services.
What’s Capitation
completely separates payment from treatment incidence. Capitation prospectively pays the provider a predetermined sum for each covered member of the plan on a regular basis (usually monthly)
What managed care products is described below:
- Contract between providers and purchasers of health care/MCOs
- Plans use pre approval, utilization review, and discounted reimbursement
- Providers have an increased pool of patients, low financial investment, and more autonomy
- Beneficiaries have a choice of providers within the panel
Preferred Provider Organizations (PPO)
What managed care products is described below:
•highly aggregated form of managed care
- Utilize gatekeepers/physicians to pre-approve
- Utilization review to control costs
- Beneficiaries access with pre-approval only, from only those providers in panel
- Provider payment varies = fee for services, case based, and capitation.
Health Maintenance Organizations (HMO)
What managed care products is described below:
•Hybrid plan containing both HMO and PPO forms of managed care
- Beneficiaries chose provider at time of service
- Benefits paid at a higher percentage within primary care/HMO provider rather than others in panel/PPO
- Rules are based on which option patient chooses
Point of Service
What managed care products is described below:
- Often used with PPO models
- Allow individuals greater control over health care utilization and spending
- To discourage overuse of services many require co-payments
- Health Savings Accounts (HSAs) often used with high deductible health plans (HDHP) can also discourage overuse of services
Consumer-Directed Health Plans
What are the different managed care products?
PPO
HMO
Point of service
consumer directed health plans
What are the 4 models of how provider contracts?
Staff model, group model, network model, and independent practice associations
Which of the 4 models of how provider contracts are established is described below?
•Providers are employed by the HMO and receive a salary
Some may provide incentives based on performance
Example: Kaiser in CA, salaries therapists and physicians, owns the hospitals
Staff model
Which of the 4 models of how provider contracts are established is described below?
▫Contract with multidisciplinary provider group practices
▫Some are captive groups
▫Non-exclusive relationship/independent group
▫Commonly seen in large multispecialty practices
Group Model
Which of the 4 models of how provider contracts are established is described below?
▫HMO contracts with multiple provider group practices, both primary and specialty
▫Similar to group model but greater geographical coverage, less integrated
Network model
Which of the 4 models of how provider contracts are established is described below?
- contract with individual providers or small provider groups
- HMO contracts with ___ to provider services to those in the HMO
- Providers keep individual and group practices and see patients from multiple HMOs
- Most commonly used by private practice OTs and PTs
IPA (Independent Practice Associations)
What may be some risks of this Staff model?
Beneficiaries receive coverage at a fixed price per month but must be treated within HMO = highly integrated
Medicare Eligibility Program eligibility is primarily determined by meeting the criteria of…?
Medicare Part A
Who is eligible for Medicare A?
- Anyone 65 years of older
- have contributed for 10 years (40 quarters)
- if no contribution can pay a monthly premium to obtain benefits
Anyone who is eligible for Medicare A is eligible for…?
Medicare B/C/D
Which medicare plan covers these services:
inpatient hospital stays, SNF, hospice, and home health care
-short rehab
Medicare Part A
Which medicare plan covers these services:
supplemental medical insurance
-professional services, outpatient, home health, DMF, prosthetics, orthotics
Medicare Part B
Which medicare plan covers these services: hospital care, doctor visits, and other medical services
- provided all benefits by Medicare Parts A and B but not hospice care
- prescription drug, dental and eye care
Medicare Part C
Which medicare plan covers these services: provides outpatient prescription drug coverage
Medicare Part D
Each resident is assessed using the______
there’s 3 parts:
Minimum Data Set (MDS)
Comprehensive description of the status and problems of the resident
The care areas assessment
Is triggered when there is a change in the MDS
Structured process by the care team to identify, analyze, address the problem
RAI (Resident Assessment Instrument)
What system is described below:
Reimbursement method that determines what services will be covered and how much will be paid for the services before
they are delivered
Resource utilization group (RUG) is the _____ system used for patients in under Medicare part A.
PPS = Perspective Payment System (1998, Newest version 2011)
What are the RUG (Resource utilization group) categories?
Ultra High Rehabilitation plus extensive services
Very High Rehabilitation plus extensive services
High Rehabilitation plus extensive services
Medium Rehabilitation plus extensive services
Low Rehabilitation plus extensive services
What payment model is described below:
Coming this October!
Use ICD-10 diagnosis and procedural codes in order to classify SNF residents into one of ten ____ Clinical Categories
Then the patient would be further classified
The idea is to provide a connection between the ICD-10 codes, the procedure codes, and the 10 ____ clinical categories
PATIENT DRIVEN PAYMENT
MODEL (PDPM)
Define Fraud
making false statements or representations of material facts to obtain benefit or payment
Define Abuse
any practice that is not consistent with the goals of providing pt with services that are medically necessary, meet professional standards, and are fairly priced
OMRA
Other medicare required assessments (OMRA)
3 types: to therapy services that are components of the RAI. These therapy intensity assessments are used to gather information for proper placement of patients into payment groups
Levels of Fraud and Abuse: Level 1
reviews the utilization pattern against a standard “edit”
Levels of Fraud and Abuse:
Level 2
a focused review by health professionals, review documentation to determine if care meets Medicare guidelines
May result in denial or referral to level III
Levels of Fraud and Abuse:
Level 3
onsite review of patient documentation and billing records
Which medicare part A benefit is described below:
Require the skills of qualified technical or professional health personnel
Must be provided directly by or under the general supervision of these skilled rehabilitation personnel
Must be provided on a daily basis with need met with inpatient care with a least 5 days a week
Services must be ordered by a physician.
SKILLED SERVICES
Which medicare part A benefit is described below:
Qualify based on home confinement and need for skilled services (rehab or nursing)
MD must confirm homebound
Can be Med A or Med B
Med A
All evaluated using OASIS (Outcome and Assessment Information Set)
Hospice
Home health agency prospective payment
HOME HEALTH CARE BENEFITS
Which medicare part A benefit is described below:
Rehabilitation hospital setting
Patients must need 3 hrs of therapy 5 days a week to qualify = “three hour rule”
“The 60% rule” = at least 60% of patients must be from certain patient diagnostic categories
Evaluated using the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI)
Inpatient rehab prospective payment
INPATIENT REHAB FACILITY BENEFITS
