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Health care delivery > Government and Entitlement Programs : Medicare > Flashcards

Government and Entitlement Programs : Medicare Flashcards

1
Q

How are payments under medicare justified?

A

payment prohibited for claims lacking information

Payment made for only claims medically necessary.

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2
Q

About 2/3 of medicare spending is ___

what about the other 1/3

A

traditional medicare

to private plans (C + D)

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3
Q

Medicare is required to pre-determine what

A

a base payment rate for service given.

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4
Q

How does medicare adjust payment for service?

A

based on location and complexity of patient.

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5
Q

List of medicare providers?

A 
Hospitals
Physicians
SNF
HHA
inpatient rehab
Hospice
Long-term care
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6
Q

Paid hospitals per beneficiary discharge

A

Acute care hospitals.

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7
Q

How are acute care hospitals paid

A

using inpatient prospective payment system..

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8
Q

Based rate for each discharge in Acute care hospital?

A

Diagnosis Related Groups

Higher payment for more intense level of care.

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9
Q

Who may receive added pay, in terms of acute care hospitals

A

teaching hospitals/ those with a high ant of low income beneficiaries .

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10
Q

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

A

Medicare IRF

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11
Q

What are cases grouped into in the Medicare IRF?

A

Rehabilitation impairment Categories

include adjustments.

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12
Q

CMS 60% rule?

A

facility must prove that at least 60% of admissions meet qualifying conditions

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13
Q

Why are IRFs paid at higher rate than rehab setting?

A

they provide rehab to pts who cannot be served in less intensive environments.

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14
Q

What are some IRF qualifying conditions?

A 
stroke
SCI
AMputaion/deformity
HipFx
brain/neuro
burn
arthritis
Jt. replacement
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15
Q

Freestanding or hospital-based facilities that provide postacute inpatient nursing and/or rehabilitation services.

A

SNF

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16
Q

Medicare pays SNFs one of ____ for each patient. what is based on?

A

66 pre-determined daily rates

based on level of nursing and therapy needs.

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17
Q

In SNFs there is a daily added payment from Medicare for care provided to pts. with

A

AIDS.

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18
Q

What does the Resident assessment process create and what does it determine?

A

Minimum Data set (MDS)

determines care plan.

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19
Q

Care in a SNF is covered with what is met.

A

1: pt. requires services
2: requires services on daily basis
3: services reasonable
4: services on inpatient basis.

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20
Q

What is the RUGS III Classification System?

A

Resident characteristic and health status.

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21
Q

Categories of RUG III

A
  • rehab + extensive service
  • impaired cognition
  • behavior probs
  • complex case
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22
Q

Rug classifications within 7 days

A 
720 mins: Ultrahigh
500 mins: Very high
325 mins: high
150 mins: Medium
45 mins: low
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23
Q

Classification for Medicare home health PART A

A
  • homebound
  • requires part time nursing/PT
  • care directed by physician
  • covers cost of first 100 Days.
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24
Q

What is OASIS used for in home health case ?

A

to assign patient to Home health resource group

determine payment rate

25
Q

for home health

how does case rate change?

A

partial episode: pt reaches goal

significant change in condition.

26
Q

Medicare B at home used when

A

Medicare A 100 ddays runs out.

27
Q

for hospice: what part of medicare is used?

A

A

from approved program.

28
Q

how is hospice payed?

A

Agency paid a daily rate for each day enrolled based on level of care regardless of whats done but

29
Q

Levels of care in hospice?

A

Routine home care
continuous home care
Inpatient respite care
General inpatient

30
Q

Payment for outservice based on

A

Resource-based relative value update scale.

31
Q

Non-physicians who bill independently typically receive a

A

15% reduction in payment.

32
Q

Majority of OP services in what 3 settings

A

Private practice
SNF
Hospital OP

33
Q

BasisforMedicareB(outpatient)payment including physical therapy

A

Resource Based Relative Value scale (RBRVS)

34
Q

what is the concept behind RBRVS

A

price paid for a service should be based on cost of providing that service.

35
Q

RBRVS based on what?

what is that divided into?

A

Relative Value units (RVU)

Work expense
Practice expense
professional liability insurance.

36
Q

In order for a service to be covered under medicare what is necessary?

A

must have benefit category in law
must be necessary and reasonable
must not be excluded.

37
Q

For medicare part B, what is necessary

A
  • individual NEEDS services

- monitored by physician and while under care.

38
Q

How is cared deemed reasonable and necessary?

A
  • must be accepted as effect Tx.
  • can only be preformed by PT
  • amt/frequency must be acceptable.
39
Q

Skilled service is when a professional needed to provide service is what goals?

A

improve limitations
maintain Fx status
Prevent deterioration of function.

40
Q

All skilled services must be provided by

A

qualified PT or PTA

41
Q

BasisforMedicareB(outpatient)payment including physical therapy

A

unskilled.

42
Q

physician’s/NPP’sapprovalofthe plan of care. Requires a dated signature on the plan of care (or other document that indicates approval of POC)

A

certification

43
Q

physician assistant, clinical nurse specialist, nurse practitioner who may certify if permitted by state and local laws

A

Nonphysician practitioner

44
Q

MD, DO, DPM, (optometrist limited to low vision).

A

Physician

45
Q

not considered physicians for therapy services and may not refer or establish therapy POC

A

Chiropractors and dentists

46
Q

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

A

Qualified Professional.

47
Q

Orders are needed for?

A
  • evidence of need for care

- certification and physician certification.

48
Q

Plans of care need to be established before

A

treatment.

eval and treatment can occur same day.

49
Q

Beneficiary must have proper notice of

A

Non coverage.

50
Q

non-covered services:

A

those not within scope: Statutorily

medically unnecessary.

51
Q

Services by PTA vs PT aides

A

PTA covered

PT not covered.

52
Q

Purpose of therapy cap?

A

to save resources needed to balance federal budget.

53
Q

When did OP hospitals include cap?

A

2012.

APTA trynna repeal.

54
Q

What did the Medicare Access and CHIP reauthorization Act of 2015 do?

A

Repealed the flawed sustainable growth rate formula.

55
Q

What are some big medicare reforms upcoming?

A

from fee-for-service-> payment on quality and outcomes

Merit based incentive payment system.

56
Q

Therapy cap for PT and OT?

A

$1,980

separate.

57
Q

MACRA ? what is considered?

A

medical review process

comparing providers
new providers
providers with claim denials.

58
Q

What is the comprehensive care joint replacement model?

A

medicare alternative payment model for elective jt. replacement.

Health care delivery (10 decks)

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