Financing Healthcare/Reimbursement Flashcards
what are the 3 major sources for health care financing?
Public, Private, Self-Pay
what is important for providers to know about pt?
Who is paying What approval/forms/documentation needed What services/financial limitations apply What is pt’s financial obligation Outcome expected for payment
What are the 2 ways to be reimbursed as an OT?
- Salaried or Fee for service employees: Facility or employee bills reimbursement source for OT service; OT paid by the facility/employer
- OT bill reimbursement source directly for service: OT paid directly by insurer/pt
what are some of the OT issues for reimbursement of services?
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”
what is the Largest single payer for OT services in US?
medicare
who does medicare cover?
Covers 65 y/o & over, permanently disabled, End Stage Renal Disease (ESRD)
what does part A of medicare cover?
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
what does part B of medicare cover?
Supplementary Medical Insurance
voluntary program
Paid by taxes and premiums
what does part C of medicare cover?
Medicare Advantage- these are Managed Care Medicare plans
what does part D of medicare cover?
Prescription drug coverage – available to anyone who has A or B; offered under “stand alone” prescription drug plans or part of Medicare C plan
what part of medicare have deductables?
all parts
Medicare A Hospital Admission /Mental Health Inpatient Stay deductables for each benefit period
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)
Medicare A Skilled Nursing Facility (SNF) Admission deductables for each benefit period
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
what are the parameters for Medicare A SNF admission?
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)
Medicare A Hospital Admission /Mental Health Inpatient Stay deductables
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
What does Medicare A & B cover for Home Health?
Part A: first 100 visits following 3 day hospital/SNF stay.
Part B: pick up additional visits or services not linked to inpt stay
What does medicare A cover for Hospice care?
No deductible but there is a small co-payment for certain drugs
what are the non-covered services of Medicare A?
Long-Term Care
Custodial Care
Personal Convenience Services
-i.e. Private duty nurses, private rooms, personal care assistance
What is the medicare B monthly premium and deductable?
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
what does medicare B cover?
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
what are the restrictions on services for medicare B?
OPD OT/PT/ST services
Skilled /medically necessary
Co-payments
Home Care
Homebound, care needed, intermittent, skilled, restorative, medically necessarily
what is the medigap program?
Private insurance purchased as supplementary to cover medical expenses not covered by Medicare
what are other ways to pick up gap (expenses not paid by medicare)?
Employer retiree insurance, out of pocket
how does medicare cover general inpatient stay?
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
what does acute inpatient rehab require?
Minimum of 2 therapies; one must be OT or PT
“3 hours of therapy a day”
how is acute inpatient rehab covered by medicare?
Paid by Case Mix Group (CMG) per single episode
how is the case mixed group determined?
by scores on IRF-PAI (inpatient rehab facility patient assessment instrument), Primary and Rehab Dx, Co-morbidities
what is the IRF-PAI assessment?
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
how long does medicare cover SNF care?
Paid up to 100 days
how does medicare reimburse SNF stays?
Payment based on Resource Utilization Group (RUG) # of minutes of therapy per week, skilled RN, dx, co-morbidities (more mins = higher $)
what is the minimum data set (MDS)
how the Resource Utilization Group (RUG) is scored
administered upon admission, at re-eval and d/c
how does medicare reimburse home health care?
Home Health Resource Group (HHRG)
how is Home health resource group (HHRG) determined?
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
how does medicare reimburse outpatient care?
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
what are the requirements for medicare reimbursement of outpatient care?
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
what does medicare require for OT service?
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
define “medically necessary” in terms of medicare
condition/impairment (new) and/or change in level of fx require skilled rehab intervention
Care is prescribed by physician
define “restorative” in terms of medicare
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
what should OT’s focus on for medicare reimbusement?
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
what should the OT evaluation include for medicare?
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
Outpatient Day Rehab time requirements
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
SNF time requirements
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
how is durable medical equipment paid for?
medicare fee schedule (80%)
Not glasses
Commode
what are prosthetics & orthotics ?
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)
what does each state determine for medicaid funds?
- Who qualifies
HOWEVER, there are categories of persons states must cover to qualify for federal $ - Reimbursement rates to providers
what is the “spend down” process?
those with incomes/financial resources above qualifying limit can use surplus on medical expenses to obtain Medicaid
what are mandatory medicaid services?
Basic services that states MUST provide to qualify for federal monies
i.e. X-rays, lab work, MD visits
what does medicaid managed care do?
Can impose managed care strategies to oversee care
how does medicaid reimbursement work in NYS?
NEEDS prior approval, medical necessity and justification
how does medicaid reimbursement work in most states?
PRIOR approval for non-routine items and equipment repairs
Able to substitute less costly item
what is workers comp and how is it reimbursed?
Compensates for work related injuries/illness,
Financed jointly by the employers and the state
what are the 4 categories of benefits for workers comp?
- Medical
- Cash for lost wages
- Cash for loss of work capacity and skill
- Survivors’ death benefits
what are common reasons for OT denials?
Technical information missing / inaccurate Incomplete forms No MD order or signature obtained Inadequate documentation Indirect service provided
