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Health Advocacy > Financing Healthcare/Reimbursement > Flashcards

Financing Healthcare/Reimbursement Flashcards

1
Q

what are the 3 major sources for health care financing?

A

Public, Private, Self-Pay

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2
Q

what is important for providers to know about pt?

A 
Who is paying
What approval/forms/documentation needed
What services/financial limitations apply
What is pt’s financial obligation
Outcome expected for payment
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3
Q

What are the 2 ways to be reimbursed as an OT?

A
  1. Salaried or Fee for service employees: Facility or employee bills reimbursement source for OT service; OT paid by the facility/employer
  2. OT bill reimbursement source directly for service: OT paid directly by insurer/pt
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4
Q

what are some of the OT issues for reimbursement of services?

A

Pay for OT in home but not in OPD
OT not “qualifying service” for ongoing services
Splint covered but not tx (or vice versa)
Limited # of visits (Caps)
Must be “in network” provider
Must be certain type of OT practitioner
Service isn’t “skilled, medically necessary”

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5
Q

what is the Largest single payer for OT services in US?

A

medicare

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6
Q

who does medicare cover?

A

Covers 65 y/o & over, permanently disabled, End Stage Renal Disease (ESRD)

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7
Q

what does part A of medicare cover?

A

Hospital Insurance
funded by taxes
Pays for current beneficiaries; retains surplus for future
Covers inpatient services in hospital, SNF, home health, hospice, no coverage for custodial care

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8
Q

what does part B of medicare cover?

A

Supplementary Medical Insurance
voluntary program
Paid by taxes and premiums

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9
Q

what does part C of medicare cover?

A

Medicare Advantage- these are Managed Care Medicare plans

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10
Q

what does part D of medicare cover?

A

Prescription drug coverage – available to anyone who has A or B; offered under “stand alone” prescription drug plans or part of Medicare C plan

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11
Q

what part of medicare have deductables?

A

all parts

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12
Q

Medicare A Hospital Admission /Mental Health Inpatient Stay deductables for each benefit period

A

Days 1–60: $0 copayment for each benefit period
Days 61–90: $304 copayment per day for each benefit period
Days 91 and beyond : $608 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over lifetime)

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13
Q

Medicare A Skilled Nursing Facility (SNF) Admission deductables for each benefit period

A

Days 1-20: $0 copayment for each benefit period
Days 21-100: $148 per day for each benefit period in 2013.
Day 101 and beyond: ALL costs for each day after day 100 in a benefit period

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14
Q

what are the parameters for Medicare A SNF admission?

A

Must occur w/in 30 days of inpatient discharge , where the inpatient stay lasted at least 3 days.

Maximal benefit for SNF is 100 days (average LOS is 35 days)

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15
Q

Medicare A Hospital Admission /Mental Health Inpatient Stay deductables

A

No co-payments/deductibles, but specific eligibility criteria
-Homebound
-Prescribed by MD
-Care must be intermittent, medical necessity, skilled
Covers skilled RN, PT, ST, NOT OT

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16
Q

What does Medicare A & B cover for Home Health?

A

Part A: first 100 visits following 3 day hospital/SNF stay.
Part B: pick up additional visits or services not linked to inpt stay

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17
Q

What does medicare A cover for Hospice care?

A

No deductible but there is a small co-payment for certain drugs

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18
Q

what are the non-covered services of Medicare A?

A

Long-Term Care
Custodial Care
Personal Convenience Services
-i.e. Private duty nurses, private rooms, personal care assistance

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19
Q

What is the medicare B monthly premium and deductable?

A

2014 - $104.90 monthly premium (note: if annual gross adjusted income > $85,000 will pay more up to $335 for those with income > $214,000)

$147 yearly deducible
80% / 20% payment

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20
Q

what does medicare B cover?

A 
physician visits
hospital OPD services
ED visits
OPD rehab
renal dialysis
radiation
DMEPOS (durable medical equipment, prosthetics, orthotics and supplies)
home health care not associated with a hospital or SNF stay
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21
Q

what are the restrictions on services for medicare B?

A

OPD OT/PT/ST services
Skilled /medically necessary
Co-payments

Home Care
Homebound, care needed, intermittent, skilled, restorative, medically necessarily

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22
Q

what is the medigap program?

A

Private insurance purchased as supplementary to cover medical expenses not covered by Medicare

23
Q

what are other ways to pick up gap (expenses not paid by medicare)?

A

Employer retiree insurance, out of pocket

24
Q

how does medicare cover general inpatient stay?

A

Diagnostic Related Group (DRG) bundled payment based on admission diagnosis
-Based on DRG, facility gets a “flat rate” to cover all costs, include rehab services

25
Q

what does acute inpatient rehab require?

A

Minimum of 2 therapies; one must be OT or PT

“3 hours of therapy a day”

26
Q

how is acute inpatient rehab covered by medicare?

A

Paid by Case Mix Group (CMG) per single episode

27
Q

how is the case mixed group determined?

A

by scores on IRF-PAI (inpatient rehab facility patient assessment instrument), Primary and Rehab Dx, Co-morbidities

28
Q

what is the IRF-PAI assessment?

A

multidisciplinary tool, includes FIM
Completed within 72 hours of admission and at d/c
Based on CMG, facility gets an “Average LOS”
IRF-PAI scores benchmarked

29
Q

how long does medicare cover SNF care?

A

Paid up to 100 days

30
Q

how does medicare reimburse SNF stays?

A 
Payment  based on Resource Utilization Group (RUG)
# of minutes of therapy per week, skilled RN, dx, co-morbidities (more mins = higher $)
31
Q

what is the minimum data set (MDS)

A

how the Resource Utilization Group (RUG) is scored

administered upon admission, at re-eval and d/c

32
Q

how does medicare reimburse home health care?

A

Home Health Resource Group (HHRG)

33
Q

how is Home health resource group (HHRG) determined?

A

by score Outcome Assessment Information Screen (OASIS) assesses medical condition, physical /mental health, B/IADL, social support systems

repeated at every 90 days and at discharge

34
Q

how does medicare reimburse outpatient care?

A

Pays via fee schedule (80% of the fee schedule) after deductible still responsible for 20%
CPT Codes used for reimbursement
i.e. therapeutic exercise, self care skills, 50 minute slot of care

35
Q

what are the requirements for medicare reimbursement of outpatient care?

A

Must be skilled, under MD approved written plan of care
Medicare MD recertification monthly
therapist evaluates and recommends if pt don’t need as much therapy
If pt wants to still come to therapy, ABN used

36
Q

what does medicare require for OT service?

A

Services performed by OTR or OTA under supervision of OTR.
NOT PERFORMED BY OT AIDE

Must provide an ABN (Advanced Beneficiary Notification) if providers think Medicare will NOT cover payment

37
Q

define “medically necessary” in terms of medicare

A

condition/impairment (new) and/or change in level of fx require skilled rehab intervention

Care is prescribed by physician

38
Q

define “restorative” in terms of medicare

A

potential for “significant improvement” within reasonable (>50% probability of improving) and predictable time

Predictable: planned freq/duration of tx estimates how long it takes to achieve goals

39
Q

what should OT’s focus on for medicare reimbusement?

A 
Function
Underlying Impairments & Deficits 
Need for Skilled Services 
Safety
State Expectations for Progress
Explain Slow/Lack of Progress
Clearly State Skilled Services 
Restorative in Nature
40
Q

what should the OT evaluation include for medicare?

A

pre-morbid level of fxing and how it’s changed with new condition
goals should be measurable, fxl, and time-specific
tx and progress notes must reflect principles listed above

41
Q

Outpatient Day Rehab time requirements

A

Documentation of therapy minutes is required

CPT procedures billed by time must have time specified in documentation

Routine re-evals NOT paid for but are required

Tx at least 2x per week or it may be considered maintenance

42
Q

SNF time requirements

A

Clear documentation of therapy minutes

Initial evaluation NOT included in minutes.

Tx at least 5X per wk at least 30 minutes each session

Increase in rehab minutes puts pt in a higher RUG category –> increases reimbursement

43
Q

how is durable medical equipment paid for?

A

medicare fee schedule (80%)
Not glasses
Commode

44
Q

what are prosthetics & orthotics ?

A 
Leg, arm, back, and neck braces,
and artificial legs, arms, and eyes, 
including replacements if required 
because of a change in the 
beneficiaries (fee schedule 80% Medicare)
45
Q

what does each state determine for medicaid funds?

A
  1. Who qualifies
    HOWEVER, there are categories of persons states must cover to qualify for federal $
  2. Reimbursement rates to providers
46
Q

what is the “spend down” process?

A

those with incomes/financial resources above qualifying limit can use surplus on medical expenses to obtain Medicaid

47
Q

what are mandatory medicaid services?

A

Basic services that states MUST provide to qualify for federal monies

i.e. X-rays, lab work, MD visits

48
Q

what does medicaid managed care do?

A

Can impose managed care strategies to oversee care

49
Q

how does medicaid reimbursement work in NYS?

A

NEEDS prior approval, medical necessity and justification

50
Q

how does medicaid reimbursement work in most states?

A

PRIOR approval for non-routine items and equipment repairs

Able to substitute less costly item

51
Q

what is workers comp and how is it reimbursed?

A

Compensates for work related injuries/illness,

Financed jointly by the employers and the state

52
Q

what are the 4 categories of benefits for workers comp?

A
  1. Medical
  2. Cash for lost wages
  3. Cash for loss of work capacity and skill
  4. Survivors’ death benefits
53
Q

what are common reasons for OT denials?

A 
Technical information missing / inaccurate
Incomplete forms
No MD order or signature  obtained
Inadequate documentation
Indirect service provided

Health Advocacy (9 decks)

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