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Intro to PT > Intro to PT Chapter 6 > Flashcards

Intro to PT Chapter 6 Flashcards

1
Q

Balanced Budget Act of 1997

A

Managed care programs and limits on Medicare reimbursements

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2
Q

risk minimization

A

reason for health insurance.

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3
Q

Patient Protection and Affordable Care Act

A

Set a minimum level of coverage and expanded health coverage to more Americans. Can’t deny coverage for pre-existing conditions for instance.

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4
Q

Health Insurance

A

A variety of policies that can be purchased to pay for certain health-related services and goods.

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5
Q

Insured

A

covered by a policy

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6
Q

subscriber

A

individual who purchases a policy

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7
Q

Covered services

A

benefits and benefit levels that cover services that will be reimbursed by the insurer under the policy

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8
Q

Durable Medical equipment

A

often not covered. (DME) - wheelchair, hospital bed or ventilator are examples given.

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9
Q

First party payment system

A

individual pays provider directly

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10
Q

second party

A

provider

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11
Q

Third party payment system

A

individual, employer, government pays insurance company or agency that pays provider.

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12
Q

health care is financed

A

By the individual, the employer or the government.

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13
Q

Major sources for health coverage under ACA for non-elderly

A

Employer sponsored insurance
Non- group market
ACA marketplaces
Traditional medicaid/chip
ACA medicaid expansion (where I get mine)
ACA market reforms.

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14
Q

Premium

A

cost of the insurance, out of pocket. In ACA marketplace low income people get subsidies from government to purchase insurance but often still have to pay a small premium In the non-group market it’s really expensive for the premium and not often done.

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15
Q

employer sponsored health insurance

A

health insurance purchased through their employers. Also known as group insurance.

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16
Q

Open enrollment

A

The period in the year where you can enroll in your employee health insurance plan. Once a plan is chosen you’re usually locked in for a year.

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17
Q

Co-pays and deductables

A

commitments the subscriber must meet directly out of pocket. Deductible is often a cash amount and may vary based on type of service. After the deductible is met the insurer will be responsible for more or all of the payments for that service.

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18
Q

Copayments

A

are a flat dollar amount the subscriber has to pay for a specific health service.

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19
Q

Coinsurence

A

a percentage cost that is covered by insurance and percentage required to be paid by subscriber. Often 80/20. Often kicks in after the deductible is met.

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20
Q

CHIP

A

Children Health Insurance Program
(like Medicaid but for children)

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21
Q

Access

A

The ability to receive health care services when needed.

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22
Q

Medicaid expansion

A

available for people up to 138% of poverty. (Some states didn’t expand Medicaid.)

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23
Q

ACA Market place subsidies

A

Available on an income basis up to 400% of level of poverty.
(When I was taking care of my father, he paid me the exact level of poverty each year which provided me with 100% subsidy on the marketplace. 400% of poverty is probably much less subsidy.)

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24
Q

Centers for Medicare and Medicaid Services (CMS)

A

Under the department of Health and Human Services. Administers Medicare (for the elderly and disabled.) and works with states to administer Medicaid. Largest purchaser of health insurance in the United States.

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25
Medicare
enacted in 1965. For people 65 and over, renal failure, disabled and entitled to social security benefits. 60 million beneficiaries.
26
Entitlement program
Americans age 65 and older who have contributed to Medicare through taxes are entitled to it.
27
Beneficiary
Individual entitled to the Medicare program. Like a subscriber.
28
Medicare Part A
Hospital insurance. Inpatient hospital care, skilled nursing facility, some home health, and hospice. Paid for by 1.45% tax on wages or taxable gross.
29
Medicare Part B
Supplementary Medical Insurance (SMI) - Funded by beneficiary premium payments matched by the government. Most people will pay $135 a month with a deductible of 185 per year. 2.5 million will have their part b increase no more than their increase in social security. High income people pay more. pays for physician services, outpatient and some home health,. Medical equipment and supplies. Physical therapy.
30
Medicare Part D
Medicare Prescription Drug plan. Federal subsidy for prescription drug insurance.
31
Medicare Prescription Drug, Improvement, and Modernization act of 2003
also referred to Medicare Modernization Act or MMA. Created Medicare Part D and went into effect 2006
32
low income seniors
7.2 million seniors who have Medicare also have Medicaid. (skilled care necessity after they take all your money.)
33
Medicare Advantage
Private insurance paid for with Medicare subsidy. Required to cover everything Medicare would have covered but not necessarily to the same degree. Must pay a premium often bigger than the Part B premium and often have co-pays and may have coinsurance. (Many seniors now consider it a scam.) The book says it offers seniors more choice as some plans cover things Medicare does not but may lack coverage in other areas. Choose A and B or Advantage (C)
34
Medicaid
Low income adult insurance. Funded by state and federal governments. 72 million people. 62.5% by federal government 37.5% by states.
35
Medicaid eligability
In states that didn't expand under ACA it required you to be at 50% of poverty level. In 2024 that's about $7500 in income or less to qualify. In states that expanded it goes to 138% of poverty level. (15,060*1.38 = $20,782)
36
low income people on disability
4.8 million low income people on disability and medicare also have medicaid
37
dual eligible people percent of Medicare spending
32%
38
Children's Health Insurance Program Reauthorization Act
feb 4 2009. Obama. Reauthorized CHIP which covers 7 million children.
39
Balanced Budget act of 1997
Clinton - Balanced the federal budget but cut entitlement spending. 115 billion for medicare and 13.6 billion for medicaid.
40
Cuts from BBA for rehabilitation providers
$1.7 million.
41
Health care costs trend
Go up much faster in USA than other developed nations. will reach 6 trillion by 2027
42
Fraud
defined as an intentional deception or misrepresentation made by a practitioner to gain a benfit to which they are not entitled. (billing for services not furnished.)
43
Abuse
involves payment for items or services when there is no legal entitlement to that payment, but the health care provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
44
waste
more common than fraud and abuse. overutilization of services that results in unnecessary costs to health care system.
45
Health Care Fraud and Abuse Control Program
started by HIPAA in 1996- in 2017 they won 2.4 billion in fraud judgements.
46
Every PT and PTA should be aware
of the patient's coverage at the beginning of each episode of care
47
payment levels
are seldom equal to a PT's full charge
48
Reimbursement
process by which health care providers recieve payment for their services.
49
Third-party payer
Intermediary that is most common in making reimbursements. Health insurance companies function as third party payers.
50
retrospective reimbursement
providers were paid after their services were rendered.
51
Fee-for-service or indemnity
traditional health insurance. provider provides care and then the provider would be paid for covered services during a given period of time
52
claims
forms describing the medical condition, services provided, and bill for services.
53
Usual, customary and reasonable range (UCR)
If the claim is within this range they are reimbursed. Insurers set their own UCR fees -- the maximum they will reimburse.
54
Fee schedual
providers base their fee schedule partly on the UCR range of insurers.
55
Prospective payment system (PPS)
payments are established in advance and the providers are paid these amounts regardless of the costs they actually incur.
56
cost control and PPS
PPS set some cost control by limiting reimbursements and incentivizing efficiency.
57
Diagnostic-related groups (DRGs)
part of Medicare part A where the patient's diagnosis determines the amount the hospital will be paid. Payment is a fixed amount based on average for treating that diagnosis.
58
Case mix (Medicare DRG)
a composite of the patients in each DRG is is used to determine reimbursement amounts. regardless of length of stay or treatment administered.
59
PPS under Part B
Resource-based relative value scale. (RBVS) Fees based on three components: 1. total work completed 2. costs to practice medicine 3. an allowance for malpractice insurance expense.
60
RVU Relative Value Unit
Medicare part B - RBVS's unit of value for each specific service. Multiplied by a national conversion factor and adjusted for geographic cost changes. - acts a cost control
61
Medicare Fee schedule
System of RBVS and RVUs became this. Lists payments for thousands of services. benchmark frequently used by third-party payers.
62
Managed Care
Health Maintenance Organization (HMO) 1973. The concept of prepaid or fixed payment under a managed care arrangement escalated. Two components: 1. Predetermined payment schedule\ 2. Provider network (panel)
63
Provider network (panel)
providers who contract with the insurance company and agree to accept the payment schedule.
64
Managed care organizations (MCOs)
All MCOs restrict access to healthcare access in some way. Effort to control utilization and ultimately to decrease costs.
65
Provider contracting
The provider is deemed "on the provider panel" or participating if it accepts the terms of the insurer's contract.
66
Provider credentialing
MCO verifies the provider's credentials.
67
utilization
delivery and cost, of health care services for a defined period of time
68
Three types of MCOs
HMOs PPOs (preferred provider organizations) POS (point of service plans)
69
HMO
Health Maintenance Organizations - after HMO act of 1973 - required employers with over 25 employees to offer HMO option if one is available in the area.
70
Staff model of HMO
providers are employed by the HMO not just under contract
71
IPA model
Independent Practice Association Model - individual physicians and physician groups form legal entities that enter into contract with the HMO. Predominate one in HMOs
72
PPO - preferred provider organization
"open managed care model" health insurers negotiates discounted or lower fees with networks of health care providers in exchange for guaranteeing a certain volume of patients. Enrollees in PPO can go out of network but pay higher co-pays, deductibles and premiums for it.
73
POS - point of service
both in network and out of network benefits. Greatest level of coverage for in network. typically has annual deductible. pays with a fixed percentage coinsurance. The insured may need to pay difference between reimbursement and the actual cost of service.
74
Primary Care Provider under HMO
chosen from a "closed panel" of participating providers. (Medicaid in South Dakota works like this.)
75
PCP as gatekeeper
decide whether or not patient needs specialist care.
76
HMO and PPO and POS main difference for network and out of network
In network HMOs are better, out of network PPO and POS are better.
77
pharmaceutical formularies
a list of drugs (usually generic) with indications for there use.
78
tiered and closed pharmaceutical formularies
closed provides coverage for a limited set of drugs. Tiered formulary rewards patients financially for using generic instead of brand-name drugs.
79
Utilization Review
evaluation of the medically necessary, appropriate, and efficient use of health care services, procedures, and facilities.
80
Case Management
provides monitoring and coordination of treatments rendered to patients to control costs and utilization.
81
2019 types of insurance employee plans
44% PPO 30%high deductible plan HMO 19% POS plan 7% 1% conventional
82
Average annual premiums for employer health insurance
$7188 for single $20,576 for family
83
Consumer-driven Health Care plans
combine high deductible with a health savings account. Pretax contributions to the accounts.
84
EHB
under ACA set of baseline features all marketplace insurance plans must meet.
85
Habilitation Services
Part of EHB that covers among other things PT.
86
Accountable Care Organization
A collaborative care model that consists of an organization of health care providers that agrees to be accountable for quality, cost and over all care. Shared savings program for Medicare providers.
87
Patient centered Medical homes (PCMH)
an approach to providing comprehensive primary care that facilitates partnerships between individual patients, their personal providers and their families.
88
value-based health care
a range of initiatives aimed at reducing costs and improving patient outcomes.
89
Value based reimbersment
requires that in order to receive payment, providers must meet certain quality thresholds while containing costs.
90
Comprehensive care for joint replacement (CJR)
monitors cost and quality of care and costs of joint replacement for Medicare.
91
Merit-Based Incentive Payment System (MIPS)
Medicare pay for performance system - CHIP 2015. -combines other systems into one - Electronic Health Records Incentive program Physician Quality Reporting System Value Based Payment Modifier.
92
Center for Medicare and Medicaid Innovation (CMMI)
New methods to pay providers based on value. Include bundles and shared savings and shared risk.
93
Third party payers, including CMS
Require labor intensive documentation for reimbursement but do not reimburse for the labor of preparing the documentation.
94
Managed care hospital stays
are often paid on a per diem basis. a per day fixed flat fee.
95
Capitation
a method of payment where a participating health care provider is paid a fixed amount in advance per member per month.
96
The Balanced Budget Act and physical therapy
imposed an arbitrary $1500 limit on outpatient PT for Medicare.
97
Moratorium on PT limit from BBA approved in
2018
98
PT and SLP threshold amount in 2019
$2040 include KX modifier for medically necessary services that exceed threshold
99
PTAs under new Medicare rules will be reimbursed at
85% the rate of PTs.
100
Current Procedural Terminology (CPT) codes
coding system required the be used by PTs.
101
CMS required coding system for PTs in SNF (skilled nursing facility)
Minimum Data Set.
102
resource Utilization Groups
part of Minimum Data Set coding that classifies residents into one of 53 groups to determine reimbursement
103
Use of evidence based practice
essential to ensure reimbursement.
104
First party Payment comeback
Problems with reimbursement have caused some PTs to require direct payment for services from clients.
105
cost sharing
Costs of health care shared by providers and consumers of health care

Intro to PT (15 decks)

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