Healthcare Reform Flashcards
Why does healthcare reform matter
- Payment for services — if PTs can not be paid, we lose our position
- Legal issues — we need to know what is allowed and not allowed under billing
What happened in 1965
Social security amendments create medicare and Medicaid
What happened in 1973
Health maintenance organization act is passed promoted pre—paid group insurance (HMO)
When is hippa established
1996
Enhanced penalties for fraud and abuse
Established medicare integrity program
What happened in 1997
Balanced budget act — medicare cap of PT services
What happened in 2010
Affordable care act (Obamacare)
What is the impact act of 2014
- Improving medicare post-acute acre transformation act
- Standardized data submission for all post-acute care facilities (and home health)
- skin integrity, functional status and cog status/change, medication reconciliation, incidence of major falls, transfer of health information, resource use information, discharge to community, all condition risk adjusted preventable hospital readmissions — all of these things impact the inpatient setting a lot
What are the four modes of healthcare financing in USA
- Out of pocket payment
- Individual private insurance
- Employment based group insurance
- Government-social insurance model
Types of insurance
- Conventional — fixed amount paid, patient pays the rest. Not currently utilized in healthcare payment
- Preferred provider Organization (PPO) — plan that allows you to see any health provider in network without referral, in network costs are much less to the patient than out of network
- Health maintenance org (HMO) — participant must choose a PCP who will direct all services needed to in network members and specialists
- Point of service — cash based model
- High deductible health plan (HDHP) — higher initial deductible cost but lower yearly or monthly premiums.
PT billing requirements
- Diagnosis coding — pathology (ICD-10) owned by World Health Org
- Procedure coding — what PT did for diagnosis (CPT) owned by American medical association
required for private practice, outpatient hospital, and Medicare part B skilled nursing facility payment
Motivation for reform
US spends more per capita than other similarly developed countries
US falls below same countries on multiple health metrics
Baby boomers are old now so impact on fiscal health of government isn’t great
Why does one need health insurance
- Important determinant to access of health care
- Uninsured: no usual source of care, less likely to have been seen by provider in last 6 months, unmet healthcare needs, worse healthcare outcomes
- Financial burden — shit is expensive without insurance
What does uncompensated care mean
People without insurance still receive medical care if needed
- Expenses are passed along: so end up with higher prices for those who can pay and higher insurance premiums
Adverse selection
More unhealthy people purchase insurance compared to healthy people
— causes high risk patient to choose higher coverage
— Insurers then: avoid covering too many high risk, high cost people (cancellation of policies, limits on lifetime payments, refusing coverage to those with pre-existing conditions)
What did affordable care act do
Signed in march of 2010 — identified 10 essential health benefits
- employer mandate
- individual mandate
- reduced uninsured in US by 32 million people
what are the 10 essential health benefits?
KNOW THIS
1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health/substance use disorder services including behavioral health
6. Prescription drugs
7. Rehab and habilitative services and devices
8. Laboratory services
9. Preventative and wellness services including chronic disease management
10. Pediatric services including oral and vision care
What is the federalist approach
December 2011 — the department of health and human services handed states the authority to develop their own essential health benefits standards
BUT the minimum benefits in one state will differ from another state. But everything on the essential health benefit standards has to be included one way or another but the way they are covered can be different.
What does employer mandate mean
Applicable large employers must be at least 95% of their full time employees and their non-spousal dependents affordable health coverage or face financial penalties
- Plan must provide minimal essential benefits and minimal value coverage of >60% of healthcare expenses
- Applicable large employers — defined as averaged at least 50 full time equivalents during the previous calendar year.
What is full time defined as
30 hours per week
What does affordable mean
Employee’s contribution does not exceed 9.5% of household income
What does individual mandate mean
Applicable individual must obtain health insurance for himself and any dependents starting in 2015
- Failure to obtain insurance will result in a monthly penalty assessed on the individual’s tax return
- Government subsidies are available for lower income families
Employer penalties
- Failure to offer opportunity for coverage
- Coverage does not include minimal coverage
- Employee’s contribution exceeds 9.5%
Exemptions to ACA
- Refuse healthcare due to religious beliefs
- Individual is not lawfully in the US
- Incarcerated individuals
- Cannot afford coverage: required contribution exceeds 8% of income and under poverty line
- Members of Indian tribes
What is health insurance marketplace
Created exchanges to provide a competitive marketplace for individuals and small employers to directly compare private healthcare options on basis on price, quality, and services
Allows individuals and smaller businesses to have purchase power.
What is the commerce clause
Gives congress the right to regulate interstate commerce
ACA affects commerce by:
1. Reducing uncompensated care costs
2. Reducing insurance premiums bu eliminating adverse selection
3. Improves the insurance marketplace.
What else did ACA do
- Expansion of Medicaid
- Allows dependents to remain on insurance until 26 yo
- Limitations on dropping insured members when sick
- Removal of lifetime coverage limits — really important esp. for peds
- Creation of health insurance rate review program
- Medical loss ration - insurers who do not spend 85% (large market) and 80% (medium market) on insurer health costs and must provide rebate to consumers
What about the expansion of Medicaid
Title XIX of SSA went into effect in July of 1965 as a federal/state welfare program
Federal poverty line in 2023 - to qualify for Medicaid must earn less than 138% of FPL before taxes
Me
Payment for performance
- A shift from payment based on VOLUME to payment based on OUTCOMES
- Means there is decreasing payment if patient experiences hospital acquired illness and decreasing payment for preventable hospital readmissions
what is previous method of payment
Fee for SERVICE only looks at services provided, not the impact of service
What does quality care mean
According to agency for healthcare research and quality — quality health care means doing the right thing at the right time in the right way for the right person and having the best results possible.
What is the hospital readmissions reductions program
- Punishes general acute care hospitals when medicare patients return for a new admission within 30 days of discharge than the government decides is appropriate
- Average penalty this fiscal year = 0.64%
- 39 Hospitals losing the maximum of 3% of reimbursement
- MORE stats on slide 46 idk if important
Accountable care organizations
Legal entity that is recognized and authorized under federal, state, and local law
A network of doctors and hospitals that share responsibility for providing care to patients
ACO patient is not required to stay in network
3 part aim for accountable care organizations
- Better care for individuals
- Better health for overall population
- Lower growth in expenditures
Qualify for Accountable Care Organizations you must…
Agree to be accountable for the overall care of the medicare beneficiaries, have adequate participation by PCPs, define process to promote evidence based medicine, report on quality and costs, and coordinate care
ACOs share in cost savings with the government
Bundled payments
Establish a pilot program to develop and evaluate paying a bundled payment for acute, inpatient hospital services, physician services, outpatient hospital services, and post acute care services for an episode of care that begins three days prior to hospitalization and spans 30 days following discharge
Patient driven pay models
- Impacts payment for skilled nursing facilities and implemented in October 2019
- Impacted group therapy definition and allowed for combined limit of 25% for group and concurrent therapy
Patient driven groupings model
- Impacts payment for home health and implemented in January 2020
- Transitions payment from 60 day to 30 day certification
- Put patient into 5 major subgroups
Prevention and wellness initiatives
- Evaluate and support employer based wellness programs
- Increased focus on wellness visits and activities in healthcare
- Improve patient/client willingness to adopt new health promotion programs
Increasing out of pocket costs to consumers
- Many plans continue to have increasing out of pocket costs for consumers for therapy services
- Serves 2 purposes
1. Off-set cost of increasing charges
2. Cost-sharing belief that when enrollee pays part of cost of care unwarranted care will be reduced.
Look at slides 65 and 66 maybe?
Talks about what might replace the ACA and the bad stuff that comes with it
What is the no surprises act
New federal protections took place Jan 1 2022 that bar insured patients from receiving surprise medical bills when they unexpectedly receive care from an out of network provider.
Either they cover the out of network or its super clear that something is NOT COVERED in their network plan
What is the American rescue plan
Recently passed American rescue plan act broadened eligibility for ACA health insurance subsidies
What is the inflation reduction act 2022
For the first time, requires the HHS secretary to negotiate prices for top selling drugs covered by medicare
Requires drug companies to pay if prices rise faster than inflation
Caps out of pocket drug spending for beneficiaries in medicare part D at $2000 annually
What are recovery audit contractors
Companies hired by the center for medicare and Medicaid services for the specific purpose of conducting audit reviews of patient charts to determine if providers were overpaid or underpaid by the medicare program
What are Red Flags for PT
- Frequency use of the KX modifier; KX modifier threshold amount is $2150 for 2022
- Billing under one PT provider number rather than separate numbers
What is the KX modifier
Provider is saying patient is different from the norm and has need for PT services beyond therapy cap
Therapy cap for 2022 is $3000 for both PT and SLP
What are risk areas for PTs
- Excessive number of codes billed per session
- Missing certification on POC
- Billing for services provided by an aide
- Providing inadequate supervision
- Billing 1:1 codes when patient participated in group therapy
- Failing to comply with 8 minute rule (for time based billing must provide direct 1:1 care for at least 8 minutes)
- Submitting claims for services that the provider knows are not reasonable and necessary
- Billing for excessive duration and frequency of services
- Billing for student services
- Documentation deficiencies
- Signatures are not legible or stamped.
