Lec 5: Gov't Entitlement Programs: Medicare Flashcards
___% of everything the US spends goes to Medicare
15%
CMS stands for
Center for Medicare and Medicaid Services
CMS was formerly known as ____?
HCFA, government agency under dept. of health and human services
What is the federal agency that managed Medicare?
CMS
Interpret the laws through…
Regulations
Medicare promulgates what?
Regulations
Medicare’s program management is by who?
Contractors (MACs)
4 Medicare “Rules”
Law
Regulations
Coverage determinations: National and Local
MedPAC
Who makes the laws?
Congress
National coverage determinations are by:
CMS
Local coverage determinations are by:
MAC or contractor
MedPAC is the _______ to congress and they have no _________
Advisory group
NO direct power
What does MedPAC do?
Will look at access, quality and payment to care and will make recommendations back
PDF handouts: Medicare (1965) is for people over the age of _____.
65
PDF handouts: If you are under the age of 65, you may be covered if you are… (3 things)
Permanently disabled
ESRD
ALS
PDF handouts: Medicare A is what?
Hospital coverage
PDF handouts: Medicare Part B is what?
OP/Ambulatory
PDF handouts: What is the difference between Medicare Part A and B?
A is the one where people pay into it over working life
B is paid for by general revenue (tax payers) and beneficiaries
PDF handouts: What is Medicare C?
Newer type of Medicare (Medicare Advantage) –> Medicare HMO
PDF handouts: What are the advantages to Medicare C?
Plans are less expensive
PDF handouts: What are the disadvantages to Medicare C?
More restrictive
PDF handouts: Medicare D is for?
Drugs
PDF handouts: Which medicare is optional?
B, you can choose to enroll there
(Can also choose Medicare Advantage C, instead of A and B
PDF handouts: What is the health status of Medicare population?
Older and sicker
Almost half have 4+ chronic conditions
PDF handouts: Most medicare beneficiaries live where?
AT HOME! Only 5% live in LTC
PDF handouts: Medicare has ______ cost-sharing requirements
HIGH
PDF handouts: Is there an annual OOP spending limit in Medicare?
NO
PDF handouts: Medicare A typically has a _______ for hospitalization after a certain about of time
Co-insurance
PDF handouts: Medicare B has a _______ _______ that people have to pay. They will also have a _____ and 20% __________
Monthly premium
Deductible
Co-insurance
PDF handouts: Medicare C and D require what?
Premiums
PDF handouts: When you have Medicare, you have high _____ spending
Out of pocket
Because you are paying premium up front and then OOP for most of services
PDF handouts: A lot of Medicare Spending/Financing goes to _______
Hospitals
PDF handouts: There is NOT a linear relationship between beneficiaries and how much you spend on them, T/F?
True
Public document for providers
CMS.gov
Public document for beneficiaries
Medicare.gov
Payment is prohibited by law for claims that what?
Lack necessary info to process the claim
Payment is made only for those services that are considered medically ______ and _______
reasonable and necessary
About ____ of Medicare spending is traditional Medicare. About ____ to private plans (Medicare C and D)
2/3 traditional
1/3 private
If you do not have to send the documentation in, how do they get it?
THEY DO AUDITS, you must present your documentation on demand if you get audited
Medicare is required to _____________ a base payment rate for a given unit of service
Pre-determine
Medicare adjusts its payment for each unit of service provided based on variables such as what?
Provider’s geographic location
Complexity of patient receiving the service
Examples of Medicare Providers?
Hospitals Physicians SNFs Home Health Agencies IRF Hospice Agencies LTC Hospitals OP Dialysis Facilities Ambulatory Surgical Centers Inpatient Psychiatric Facilities DME suppliers Ambulance providers Labs
Acute Care Hospitals: Paid hospitals per beneficiary discharge using the ______
Inpatient Prospective Payment System
Acute Care Hospitals: Base rate for each ________: __________; further adjusted for patient ________
Discharge
Diagnosis Related Groups
Severity
Acute Care Hospitals: Higher payment for DRGs that are likely to incur more ______ levels of care and/or _____ lengths of stay
Intense
Longer
Acute Care Hospitals: Also account for a portion of hospitals’ _______ and _________
capital
operating expenses
Acute Care Hospitals: Some ________ hospitals or those with higher shares of ________ beneficiaries receive added payments
Teaching
Low-income
Acute Care Hospitals: You get paid by _______
Diagnosis
Medicare IRF: Rates based on _____ _______ _____ which is the relative resource intensity that would be associated with each patient’s clinical condition as identified through resident assessment process (_______)
Patient case mix
IRF-PAI
Medicare IRF: Cases grouped into ____ ______ ______
Rehab Impairment Categories
Medicare IRF: Also includes facility level adjustments, T/F?
True
The CMS 60% Rule that’s that IRFs are paid at _______ rate than other rehab setting
HIGHER
CMS 60% Rule: Provide intensive rehab services to patients who cannot be service in what kind of environments?
Less intensive
CMS 60% rule: What do patients need to have for admission?
Qualifying conditions
According to the CMS 60% rule, facility must prove that at least ____ of admissions meet qualifying conditions
60%
Examples of CMS IRF Qualifying Conditions
Stroke SCI Congenital deformity Amputation Major multiple trauma Fracture of femur Brain injury Neuro disorders Burns Arthritis related medical conditions -3 (complex) Knee or hip joint replacement (complex)
Skilled Nursing Facilities: Freestanding or hospital based facilities that provide what kind of services?
Postacute inpatient nursing
And/or
Rehab services
Skilled Nursing Facilities: Medicare pays SNFs one of ____ pre-determined daily rates (categorized as ______) for each patient, based on patients’ expected level of nursing and therapy needs
66
Resource Utilization Groups (RUGs)
Skilled Nursing Facilities: SNF payments incorporate ______ and _____ costs for providing care to Medicare patients
Operating
Capital
Skilled Nursing Facilities: there is an added family payment from medicare for care provided to beneficiaries with _____
AIDS
Skilled Nursing Facilities: ______ necessity for skilled nursing and/or rehab services
Physician
Skilled Nursing Facilities: Resident assessment process, created __________, which determine the care plan
Minimum data set (MDS)
Skilled Nursing Facilities: The RUGS III Classification system looks at what?
Resident characteristics and health status
Skilled Nursing Facilities: What is payment based on?
RUGS relative resource, cost from high to low
Skilled Nursing Facilities: How is payment measure?
In minutes of care
CARE IN A SNF IS COVERED IF ALL OF THE FOLLOWING 4 FACTORS ARE MET. What are they?
- Pt requires skilled nursing services or skilled rehab services (performed under supervision of professional or technical personnel) and order by a physician
- Pt requires these skilled services on a DAILY BASIS
- The daily skilled services can be provided only on an INPATIENT bases in a SNF
- Services must be REASONABLE AND NECESSARY
Examples of minimum data set categories
Cognition Communication Vision Mood/Behavior Physical function Continence Psychological Medical Dx Health Condition (last 7 days) Pain Oral/Nutrition Skin condition Activity pursuit patterns Medication Specific treatment procedures Discharge potential
RUG III Categories
Rehab plus extensive services Rehab Extensive services Special care Clinically complex Impaired cog Behavior problems Reduced physical function
RUG classifications (rehab): Within last 7 days, at least 5 days: ULTRA HIGH:
720 minutes of more, at least 2 disciplines
RUG classifications (rehab): Within last 7 days, at least 5 days: VERY HIGH:
500 minutes, at least one discipline
RUG classifications (rehab): Within last 7 days, at least 5 days: HIGH:
325 minutes, at least one discipline
RUG classifications (rehab): Within last 7 days, at least 5 days: Medium:
150 or more minutes, any combination of 3 disciplines
RUG classifications (rehab): Within last 7 days, at least 5 days: Low:
45 minutes 3 days any combo 3 disciplines AND 2 or more rehab nursing services
Medicare Home Health Services (PART A): Must be ________
Home bound
Medicare Home Health Services (PART A) Patient requires ______ initial skilled nursing, PT and/or ST< or continuing OT
PART TIME
Medicare Home Health Services (PART A): Care must be directed by a ______
Physician
Medicare Home Health Services (PART A): Must be provided by ___________ HHA
Medicare Certified
Medicare Home Health Services (PART A): Covers cost of what?
First 100 days after prior 3-day hospital stay
Home Health Care Rate: What tool is used to assign patient to home health resource group (HHRG)?
OASIS
Home Health Care Rate: OASIS will determine what?
Payment rate
Home Health Care Rate: _____ day episode as basic unit of payment
60
Home Health Care Rate: What are two instances of case rate changes?
1) Partial episode payment - beneficiary reaches goals
2) Significant change in condition adjustment - patient change from initial POC
Medicare B at home: Coverage when?
100 day Part A benefit exhausted OR
3-day hospital stay requirement not met
Medicare Hospice Benefit: Part __
A
Medicare Hospice Benefit: The individual is certified as having _______ with a prognosis of _________ if the illness runs its normal course
Terminal illness
6 months or less
Medicare Hospice Benefit: The individual receives care from what?
Medicare approved hospice program
Medicare Hospice Benefit: Individual must sign a statement indicating that he or she elects the hospice benefit and _______ all other rights to Medicare payments for services for the terminal illness and related conditions
WAIVES
Hospice Services Covered includes:
Physician services
Nursing care
Medical equipment/supplies
Drugs for symptom control and pain relief
Hospice aid and homemaker services
PT
OT
SLP
Social Worker
Dietary counseling
Spiritual counseling
Grief and loss counseling for the individual and his/her family
Short term inpatient care for pain control and Sx management and for respite care
Any other services as IDed by the hospice interdisciplinary group
Hospice Payment Rates: Agencies paid a _______ rate for each day a beneficiary is enrolled in hospice benefit
Daily
Hospice Payment Rates: T/F: Payments are made regardless of the amount of services furnished on a given day and are intended to cover costs that the hospice incurs in furnishing services IDed in POC
True
Hospice Payment Rates: Payments are based on the level of care required to meet beneficiary and family needs: What are 4 types of home care?
Routine home care
Continuous home care
Inpatient respite care
General inpatient care
Outpatient providers: Medicare and other services provided by a ______ or _______
Hospital
Other qualified provider
Outpatient providers: Increased utilization after__________ and fewer restrictions on care
Hospital DRGs
Outpatient providers: Based on a ___________ for over 7000 services
Medicare Fee Schedule (MPFS)
Outpatient providers: Payment rates based on _______, since 1992
Resource Based Relative Value Update Scale (RBRVS)
Outpatient providers: Bonuses are given to physicians in designated ________
Shortage areas
Outpatient providers: Non physicians who bill independently typically receive a ____% reduction in payment
15%
Utilization of OP Therapy Services: PT = __% of OP rehab benefit under Medicare
88%
Utilization of OP Therapy Services: Majority in what 3 settings?
Private Practice
SNF
Hospital OP
Resource Based Relative Value Scale (RBRVS): Basis for Medicare _____ payment including PT
Part B (outpatient)
Resource Based Relative Value Scale (RBRVS): Concept: the price paid for a service should be based on what?
The cost of providing that service
Resource Based Relative Value Scale (RBRVS): Services classified and reported to CMS using what system?
Healthcare Common Procedure Coding System (LEVEL 1) via CPT
Resource Based Relative Value Scale (RBRVS): Payment rates based on relative weights called _______ divided into three categories or relative costliness of inputs used to provide services
Relative Value units (RVUs)
Resource Based Relative Value Scale (RBRVS): What are the 3 categories?
Work expense/value
Practice expense
Professional Liability Insurance (PLI) - malpractice expenses
Medical necessity under Medicare: In order for a service to be covered under Medicare, it must have 3 things:
Must have a benefit category in the law
Must not be excluded
Must be reasonable and necessary
Medicare Conditions of Payment (Part B): Services required because individual ______ therapy services
NEEDS
Medicare Conditions of Payment (Part B): Plan is establish by who? And is periodically review by who?
Physician/NPP
Physician/NPP
Medicare Conditions of Payment (Part B): Services provided while individual is what?
Under the care of a physician
Medicare Conditions of Payment (Part B): Furnished on ____ Basis
OP
Medical Necessity: Medicare benefit for therapy requires that the patient be under the care of a _______ for some diagnosis
Physician
Medical Necessity is determined by who?
Evaluating PT
Medical Necessity: Must be clear evidence of medical necessity documented in _________
PT DOCUMENTATION
Reasonable and Necessary: EACH OF THE FOLLOWING CONDITIONS MUST BE MET (4)
1) Services considered under accepted standards of medical practice to be a SPECIFIC AND EFFECTIVE Tx for pt’s condition
2) Services are COMPLEX, or condition of patient requires, that services can ONLY be performed by a therapist or under supervision or therapist
3) PT diagnosis is NOT sole factor in determining skill - key determinants are need for therapist to treat illness, injury or disease process and whether services needed could by provided by other nonskilled personnel
4) Amt, freq and duration of therapy services must be reasonable according to accepted standard of practice
Skilled services: When the knowledge, abilities and clinical judgment of a therapist are necessary to safely and effectively furnish a therapy service for one of the following goals:
- Improvement of impairment or functional limitation
- Maintenance of functional status
- Prevention or slowing further deterioration in function
Skilled services must be provided by ________ or ________
Qualified professional (therapist) Or Qualified personnel (PTA)
Skilled services: once patient is judged safe for independent performance of an activity, skill of a therapist is ________ and services are __________
Not required
No longer reasonable or necessary
Services provided by those who do not meet CMS qualification standards are not __________
Considered skilled
Services that are ________ or reinforce previously learned skills, or maintain function after a maintenance program is developed are considered _________
Repetitive
UNSKILLED
What happened in Jimmy vs. Sibelius?
Class action law suit for Medicare beneficiaries that were denied services based on an arbitrary policy that denied coverage of PT and nursing services because there was no material improvement in patient’s condition
There should be no improvement standard
Even when no improvement is possible, skilled maintenance therapy to prevent or slow deterioration is important!
There is a clear distinction now between restorative or rehabilitative therapy and maintenance thereapy
In restorative/rehabilitative care, what is the primary goal?
To reverse loss in function, and therefore assessing the potential for improvement is appropriate
In maintenance therapy, what is coverage based on
Improvement is not expected and should not determine coverage of care.
Coverage is based on an individualized assessment of the pt’s condition and the NEED FOR SKILLED CARE to carry out safe and effective maintenance program
Certification:
Physician’s/NPP’s approval of the POC
Requires a dated signature on the POC
Non Physician Practioner (NPP):
PA, CNS, NP who may certify if permitted by state and local laws
Physician:
MD, DO, DPM
Chiros and dentists not considered physicians for therapy services and may not refer or establish POC
Qualified professional:
PT, OT, SLP, MD, NP, CNS, 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
An order/referral for therapy service provides _______ of both the need for care and that the patient is under the care of a physician
Evidence
Certification requirements for order/referrals are met when the _____ certifies the POC
Physician
Payment is dependent on the _________ of the POC rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan
CERTIFICATION
Plans of care must be established ________ treatment begins
Before
POC may be established by _______ or _______
MD/NPP
Or
Therapist provider
Evaluation and treatment may occur and are billable on ________
Same day
Payment for services provided before plan is established may be ______
Denied
Medicare (billing beneficiary directly): Beneficiary must have proper notice of ________
Non coverage (ABN)
Medicare (billing beneficiary directly): What are non covered services?
Statutorily non covered (not within scope of Medicare)
Not covered as determined to be medically unnecessary
Medicare and PTAs: The services are billed by who?
The supervising PT
Medicare and PTAs: PTAs may not do what?
They cannot provide eval services
Make clinical judgments or decisions
Or take responsibility for the service
Medicare and PTAs: General supervision is required for all PTAs in all settings except ______ (which requires direct supervision)
PRIVATE PRACTICE
“Incident To” Services: Statute requires that payment be made for a therapy service billed by a physician/NPP only if the service meets the standards and conditions – other than licensing – that would apply to a therapist, T/F??
True
Therapy Cap: In 1997, Congress passed the _____________ that created an annual financial limit on PT and SLP, and a separate cap on OT, for all OP settings
Balanced Budget Act
Therapy Cap: Balanced Budget Act sole purpose was what?
To save resources needed to balance the federal budget
Therapy Cap: Exceptions process:
Automatic exceptions for conditions IDed by CMS – refers to ___________
Processing of claims
Therapy Cap Exceptions process: Uses of a _____ modifier
KX
Examples of conditions likely to qualify for PT
Joint replacement Amputation OA Osteoporosis Fracture SCI Head injury Gait abnormality
What does MACRA stand for?
Medicare Access and CHIP Reauth Act
MACRA repealed what?
The flawed sustainable growth rate (SRG) formula
MACRA further extended the ___________ exceptions process to 12/31/17
Medicare therapy cap
MACRA began policy changes toward other significant Medicare reforms: Framework to move Medicare from a largely ________ program to a program that bases payment on _____ and _______
Fee for service
Quality
Improved outcomes
With MACRA, CMS will determine which therapy services to renew by considering (3)
1) reviewing providers with patterns of aberrant billing practices
2) providers with high claims denial % or who are less competent with applicable Medicare program requirements
3) newly enrolled providers
Comprehensive Care Joint Replacement Model:
Medicare alternate payment model for elective HIP and KNEE jt replacement patients
Comprehensive Care Joint Replacement Model: Payment is linked to _____ measurement and improved _________
Quality
Outcomes of care
