Government and Entitlement Programs : Medicare Flashcards
How are payments under medicare justified?
payment prohibited for claims lacking information
Payment made for only claims medically necessary.
About 2/3 of medicare spending is ___
what about the other 1/3
traditional medicare
to private plans (C + D)
Medicare is required to pre-determine what
a base payment rate for service given.
How does medicare adjust payment for service?
based on location and complexity of patient.
List of medicare providers?
Hospitals Physicians SNF HHA inpatient rehab Hospice Long-term care
Paid hospitals per beneficiary discharge
Acute care hospitals.
How are acute care hospitals paid
using inpatient prospective payment system..
Based rate for each discharge in Acute care hospital?
Diagnosis Related Groups
Higher payment for more intense level of care.
Who may receive added pay, in terms of acute care hospitals
teaching hospitals/ those with a high ant of low income beneficiaries .
Rates based on patient case mix which is relative resource intensity that would be associated with each patient’s clinical condition as identified through resident assessment process
Medicare IRF
What are cases grouped into in the Medicare IRF?
Rehabilitation impairment Categories
include adjustments.
CMS 60% rule?
facility must prove that at least 60% of admissions meet qualifying conditions
Why are IRFs paid at higher rate than rehab setting?
they provide rehab to pts who cannot be served in less intensive environments.
What are some IRF qualifying conditions?
stroke SCI AMputaion/deformity HipFx brain/neuro burn arthritis Jt. replacement
Freestanding or hospital-based facilities that provide postacute inpatient nursing and/or rehabilitation services.
SNF
Medicare pays SNFs one of ____ for each patient. what is based on?
66 pre-determined daily rates
based on level of nursing and therapy needs.
In SNFs there is a daily added payment from Medicare for care provided to pts. with
AIDS.
What does the Resident assessment process create and what does it determine?
Minimum Data set (MDS)
determines care plan.
Care in a SNF is covered with what is met.
1: pt. requires services
2: requires services on daily basis
3: services reasonable
4: services on inpatient basis.
What is the RUGS III Classification System?
Resident characteristic and health status.
Categories of RUG III
- rehab + extensive service
- impaired cognition
- behavior probs
- complex case
Rug classifications within 7 days
720 mins: Ultrahigh 500 mins: Very high 325 mins: high 150 mins: Medium 45 mins: low
Classification for Medicare home health PART A
- homebound
- requires part time nursing/PT
- care directed by physician
- covers cost of first 100 Days.
What is OASIS used for in home health case ?
to assign patient to Home health resource group
determine payment rate
for home health
how does case rate change?
partial episode: pt reaches goal
significant change in condition.
Medicare B at home used when
Medicare A 100 ddays runs out.
for hospice: what part of medicare is used?
A
from approved program.
how is hospice payed?
Agency paid a daily rate for each day enrolled based on level of care regardless of whats done but
Levels of care in hospice?
Routine home care
continuous home care
Inpatient respite care
General inpatient
Payment for outservice based on
Resource-based relative value update scale.
Non-physicians who bill independently typically receive a
15% reduction in payment.
Majority of OP services in what 3 settings
Private practice
SNF
Hospital OP
BasisforMedicareB(outpatient)payment including physical therapy
Resource Based Relative Value scale (RBRVS)
what is the concept behind RBRVS
price paid for a service should be based on cost of providing that service.
RBRVS based on what?
what is that divided into?
Relative Value units (RVU)
Work expense
Practice expense
professional liability insurance.
In order for a service to be covered under medicare what is necessary?
must have benefit category in law
must be necessary and reasonable
must not be excluded.
For medicare part B, what is necessary
- individual NEEDS services
- monitored by physician and while under care.
How is cared deemed reasonable and necessary?
- must be accepted as effect Tx.
- can only be preformed by PT
- amt/frequency must be acceptable.
Skilled service is when a professional needed to provide service is what goals?
improve limitations
maintain Fx status
Prevent deterioration of function.
All skilled services must be provided by
qualified PT or PTA
BasisforMedicareB(outpatient)payment including physical therapy
unskilled.
physician’s/NPP’sapprovalofthe plan of care. Requires a dated signature on the plan of care (or other document that indicates approval of POC)
certification
physician assistant, clinical nurse specialist, nurse practitioner who may certify if permitted by state and local laws
Nonphysician practitioner
MD, DO, DPM, (optometrist limited to low vision).
Physician
not considered physicians for therapy services and may not refer or establish therapy POC
Chiropractors and dentists
PT,OT,SLP,MD,NP, CNS or PA, licensed or certified by state to perform therapy services. May include PTA and COTA under supervision of qualified therapist as allowed by state law
Qualified Professional.
Orders are needed for?
- evidence of need for care
- certification and physician certification.
Plans of care need to be established before
treatment.
eval and treatment can occur same day.
Beneficiary must have proper notice of
Non coverage.
non-covered services:
those not within scope: Statutorily
medically unnecessary.
Services by PTA vs PT aides
PTA covered
PT not covered.
Purpose of therapy cap?
to save resources needed to balance federal budget.
When did OP hospitals include cap?
2012.
APTA trynna repeal.
What did the Medicare Access and CHIP reauthorization Act of 2015 do?
Repealed the flawed sustainable growth rate formula.
What are some big medicare reforms upcoming?
from fee-for-service-> payment on quality and outcomes
Merit based incentive payment system.
Therapy cap for PT and OT?
$1,980
separate.
MACRA ? what is considered?
medical review process
comparing providers
new providers
providers with claim denials.
What is the comprehensive care joint replacement model?
medicare alternative payment model for elective jt. replacement.
