Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Healthcare Delivery- JD > Lec 5: Gov't Entitlement Programs: Medicare > Flashcards

Lec 5: Gov't Entitlement Programs: Medicare Flashcards

1
Q

___% of everything the US spends goes to Medicare

A

15%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

CMS stands for

A

Center for Medicare and Medicaid Services

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

CMS was formerly known as ____?

A

HCFA, government agency under dept. of health and human services

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the federal agency that managed Medicare?

A

CMS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Interpret the laws through…

A

Regulations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Medicare promulgates what?

A

Regulations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Medicare’s program management is by who?

A

Contractors (MACs)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

4 Medicare “Rules”

A

Law
Regulations
Coverage determinations: National and Local
MedPAC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Who makes the laws?

A

Congress

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

National coverage determinations are by:

A

CMS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Local coverage determinations are by:

A

MAC or contractor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

MedPAC is the _______ to congress and they have no _________

A

Advisory group

NO direct power

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What does MedPAC do?

A

Will look at access, quality and payment to care and will make recommendations back

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

PDF handouts: Medicare (1965) is for people over the age of _____.

A

65

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

PDF handouts: If you are under the age of 65, you may be covered if you are… (3 things)

A

Permanently disabled
ESRD
ALS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

PDF handouts: Medicare A is what?

A

Hospital coverage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

PDF handouts: Medicare Part B is what?

A

OP/Ambulatory

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

PDF handouts: What is the difference between Medicare Part A and B?

A

A is the one where people pay into it over working life

B is paid for by general revenue (tax payers) and beneficiaries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

PDF handouts: What is Medicare C?

A

Newer type of Medicare (Medicare Advantage) –> Medicare HMO

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

PDF handouts: What are the advantages to Medicare C?

A

Plans are less expensive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

PDF handouts: What are the disadvantages to Medicare C?

A

More restrictive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

PDF handouts: Medicare D is for?

A

Drugs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

PDF handouts: Which medicare is optional?

A

B, you can choose to enroll there

(Can also choose Medicare Advantage C, instead of A and B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

PDF handouts: What is the health status of Medicare population?

A

Older and sicker

Almost half have 4+ chronic conditions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

PDF handouts: Most medicare beneficiaries live where?

A

AT HOME! Only 5% live in LTC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

PDF handouts: Medicare has ______ cost-sharing requirements

A

HIGH

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

PDF handouts: Is there an annual OOP spending limit in Medicare?

A

NO

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

PDF handouts: Medicare A typically has a _______ for hospitalization after a certain about of time

A

Co-insurance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

PDF handouts: Medicare B has a _______ _______ that people have to pay. They will also have a _____ and 20% __________

A

Monthly premium
Deductible
Co-insurance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

PDF handouts: Medicare C and D require what?

A

Premiums

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

PDF handouts: When you have Medicare, you have high _____ spending

A

Out of pocket

Because you are paying premium up front and then OOP for most of services

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

PDF handouts: A lot of Medicare Spending/Financing goes to _______

A

Hospitals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

PDF handouts: There is NOT a linear relationship between beneficiaries and how much you spend on them, T/F?

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Public document for providers

A

CMS.gov

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Public document for beneficiaries

A

Medicare.gov

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Payment is prohibited by law for claims that what?

A

Lack necessary info to process the claim

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Payment is made only for those services that are considered medically ______ and _______

A

reasonable and necessary

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

About ____ of Medicare spending is traditional Medicare. About ____ to private plans (Medicare C and D)

A

2/3 traditional

1/3 private

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

If you do not have to send the documentation in, how do they get it?

A

THEY DO AUDITS, you must present your documentation on demand if you get audited

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Medicare is required to _____________ a base payment rate for a given unit of service

A

Pre-determine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Medicare adjusts its payment for each unit of service provided based on variables such as what?

A

Provider’s geographic location

Complexity of patient receiving the service

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Examples of Medicare Providers?

A 
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Acute Care Hospitals: Paid hospitals per beneficiary discharge using the ______

A

Inpatient Prospective Payment System

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Acute Care Hospitals: Base rate for each ________: __________; further adjusted for patient ________

A

Discharge
Diagnosis Related Groups
Severity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Acute Care Hospitals: Higher payment for DRGs that are likely to incur more ______ levels of care and/or _____ lengths of stay

A

Intense

Longer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Acute Care Hospitals: Also account for a portion of hospitals’ _______ and _________

A

capital

operating expenses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Acute Care Hospitals: Some ________ hospitals or those with higher shares of ________ beneficiaries receive added payments

A

Teaching

Low-income

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Acute Care Hospitals: You get paid by _______

A

Diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

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 (_______)

A

Patient case mix

IRF-PAI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Medicare IRF: Cases grouped into ____ ______ ______

A

Rehab Impairment Categories

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Medicare IRF: Also includes facility level adjustments, T/F?

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

The CMS 60% Rule that’s that IRFs are paid at _______ rate than other rehab setting

A

HIGHER

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

CMS 60% Rule: Provide intensive rehab services to patients who cannot be service in what kind of environments?

A

Less intensive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

CMS 60% rule: What do patients need to have for admission?

A

Qualifying conditions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

According to the CMS 60% rule, facility must prove that at least ____ of admissions meet qualifying conditions

A

60%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Examples of CMS IRF Qualifying Conditions

A 
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)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Skilled Nursing Facilities: Freestanding or hospital based facilities that provide what kind of services?

A

Postacute inpatient nursing
And/or
Rehab services

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

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

A

66

Resource Utilization Groups (RUGs)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Skilled Nursing Facilities: SNF payments incorporate ______ and _____ costs for providing care to Medicare patients

A

Operating

Capital

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Skilled Nursing Facilities: there is an added family payment from medicare for care provided to beneficiaries with _____

A

AIDS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Skilled Nursing Facilities: ______ necessity for skilled nursing and/or rehab services

A

Physician

62
Q

Skilled Nursing Facilities: Resident assessment process, created __________, which determine the care plan

A

Minimum data set (MDS)

63
Q

Skilled Nursing Facilities: The RUGS III Classification system looks at what?

A

Resident characteristics and health status

64
Q

Skilled Nursing Facilities: What is payment based on?

A

RUGS relative resource, cost from high to low

65
Q

Skilled Nursing Facilities: How is payment measure?

A

In minutes of care

66
Q

CARE IN A SNF IS COVERED IF ALL OF THE FOLLOWING 4 FACTORS ARE MET. What are they?

A
  1. Pt requires skilled nursing services or skilled rehab services (performed under supervision of professional or technical personnel) and order by a physician
  2. Pt requires these skilled services on a DAILY BASIS
  3. The daily skilled services can be provided only on an INPATIENT bases in a SNF
  4. Services must be REASONABLE AND NECESSARY
67
Q

Examples of minimum data set categories

A 
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
68
Q

RUG III Categories

A 
Rehab plus extensive services
Rehab
Extensive services
Special care
Clinically complex
Impaired cog
Behavior problems
Reduced physical function
69
Q 
RUG classifications (rehab): Within last 7 days, at least 5 days:
ULTRA HIGH:
A

720 minutes of more, at least 2 disciplines

70
Q 
RUG classifications (rehab): Within last 7 days, at least 5 days:
VERY HIGH:
A

500 minutes, at least one discipline

71
Q 
RUG classifications (rehab): Within last 7 days, at least 5 days:
HIGH:
A

325 minutes, at least one discipline

72
Q 
RUG classifications (rehab): Within last 7 days, at least 5 days:
Medium:
A

150 or more minutes, any combination of 3 disciplines

73
Q 
RUG classifications (rehab): Within last 7 days, at least 5 days:
Low:
A

45 minutes 3 days any combo 3 disciplines AND 2 or more rehab nursing services

74
Q

Medicare Home Health Services (PART A): Must be ________

A

Home bound

75
Q

Medicare Home Health Services (PART A) Patient requires ______ initial skilled nursing, PT and/or ST< or continuing OT

A

PART TIME

76
Q

Medicare Home Health Services (PART A): Care must be directed by a ______

A

Physician

77
Q

Medicare Home Health Services (PART A): Must be provided by ___________ HHA

A

Medicare Certified

78
Q

Medicare Home Health Services (PART A): Covers cost of what?

A

First 100 days after prior 3-day hospital stay

79
Q

Home Health Care Rate: What tool is used to assign patient to home health resource group (HHRG)?

A

OASIS

80
Q

Home Health Care Rate: OASIS will determine what?

A

Payment rate

81
Q

Home Health Care Rate: _____ day episode as basic unit of payment

A

60

82
Q

Home Health Care Rate: What are two instances of case rate changes?

A

1) Partial episode payment - beneficiary reaches goals

2) Significant change in condition adjustment - patient change from initial POC

83
Q

Medicare B at home: Coverage when?

A

100 day Part A benefit exhausted OR

3-day hospital stay requirement not met

84
Q

Medicare Hospice Benefit: Part __

A

A

85
Q

Medicare Hospice Benefit: The individual is certified as having _______ with a prognosis of _________ if the illness runs its normal course

A

Terminal illness

6 months or less

86
Q

Medicare Hospice Benefit: The individual receives care from what?

A

Medicare approved hospice program

87
Q

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

A

WAIVES

88
Q

Hospice Services Covered includes:

A

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

89
Q

Hospice Payment Rates: Agencies paid a _______ rate for each day a beneficiary is enrolled in hospice benefit

A

Daily

90
Q

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

A

True

91
Q

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?

A

Routine home care
Continuous home care
Inpatient respite care
General inpatient care

92
Q

Outpatient providers: Medicare and other services provided by a ______ or _______

A

Hospital

Other qualified provider

93
Q

Outpatient providers: Increased utilization after__________ and fewer restrictions on care

A

Hospital DRGs

94
Q

Outpatient providers: Based on a ___________ for over 7000 services

A

Medicare Fee Schedule (MPFS)

95
Q

Outpatient providers: Payment rates based on _______, since 1992

A

Resource Based Relative Value Update Scale (RBRVS)

96
Q

Outpatient providers: Bonuses are given to physicians in designated ________

A

Shortage areas

97
Q

Outpatient providers: Non physicians who bill independently typically receive a ____% reduction in payment

A

15%

98
Q

Utilization of OP Therapy Services: PT = __% of OP rehab benefit under Medicare

A

88%

99
Q

Utilization of OP Therapy Services: Majority in what 3 settings?

A

Private Practice
SNF
Hospital OP

100
Q

Resource Based Relative Value Scale (RBRVS): Basis for Medicare _____ payment including PT

A

Part B (outpatient)

101
Q

Resource Based Relative Value Scale (RBRVS): Concept: the price paid for a service should be based on what?

A

The cost of providing that service

102
Q

Resource Based Relative Value Scale (RBRVS): Services classified and reported to CMS using what system?

A

Healthcare Common Procedure Coding System (LEVEL 1) via CPT

103
Q

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

A

Relative Value units (RVUs)

104
Q

Resource Based Relative Value Scale (RBRVS): What are the 3 categories?

A

Work expense/value
Practice expense
Professional Liability Insurance (PLI) - malpractice expenses

105
Q

Medical necessity under Medicare: In order for a service to be covered under Medicare, it must have 3 things:

A

Must have a benefit category in the law
Must not be excluded
Must be reasonable and necessary

106
Q

Medicare Conditions of Payment (Part B): Services required because individual ______ therapy services

A

NEEDS

107
Q

Medicare Conditions of Payment (Part B): Plan is establish by who? And is periodically review by who?

A

Physician/NPP

Physician/NPP

108
Q

Medicare Conditions of Payment (Part B): Services provided while individual is what?

A

Under the care of a physician

109
Q

Medicare Conditions of Payment (Part B): Furnished on ____ Basis

A

OP

110
Q

Medical Necessity: Medicare benefit for therapy requires that the patient be under the care of a _______ for some diagnosis

A

Physician

111
Q

Medical Necessity is determined by who?

A

Evaluating PT

112
Q

Medical Necessity: Must be clear evidence of medical necessity documented in _________

A

PT DOCUMENTATION

113
Q

Reasonable and Necessary: EACH OF THE FOLLOWING CONDITIONS MUST BE MET (4)

A

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

114
Q

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:

A
  • Improvement of impairment or functional limitation
  • Maintenance of functional status
  • Prevention or slowing further deterioration in function
115
Q

Skilled services must be provided by ________ or ________

A 
Qualified professional (therapist)
Or
Qualified personnel (PTA)
116
Q

Skilled services: once patient is judged safe for independent performance of an activity, skill of a therapist is ________ and services are __________

A

Not required

No longer reasonable or necessary

117
Q

Services provided by those who do not meet CMS qualification standards are not __________

A

Considered skilled

118
Q

Services that are ________ or reinforce previously learned skills, or maintain function after a maintenance program is developed are considered _________

A

Repetitive

UNSKILLED

119
Q

What happened in Jimmy vs. Sibelius?

A

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

120
Q

In restorative/rehabilitative care, what is the primary goal?

A

To reverse loss in function, and therefore assessing the potential for improvement is appropriate

121
Q

In maintenance therapy, what is coverage based on

A

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

122
Q

Certification:

A

Physician’s/NPP’s approval of the POC

Requires a dated signature on the POC

123
Q

Non Physician Practioner (NPP):

A

PA, CNS, NP who may certify if permitted by state and local laws

124
Q

Physician:

A

MD, DO, DPM

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

125
Q

Qualified professional:

A

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

126
Q

An order/referral for therapy service provides _______ of both the need for care and that the patient is under the care of a physician

A

Evidence

127
Q

Certification requirements for order/referrals are met when the _____ certifies the POC

A

Physician

128
Q

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

A

CERTIFICATION

129
Q

Plans of care must be established ________ treatment begins

A

Before

130
Q

POC may be established by _______ or _______

A

MD/NPP
Or
Therapist provider

131
Q

Evaluation and treatment may occur and are billable on ________

A

Same day

132
Q

Payment for services provided before plan is established may be ______

A

Denied

133
Q

Medicare (billing beneficiary directly): Beneficiary must have proper notice of ________

A

Non coverage (ABN)

134
Q

Medicare (billing beneficiary directly): What are non covered services?

A

Statutorily non covered (not within scope of Medicare)

Not covered as determined to be medically unnecessary

135
Q

Medicare and PTAs: The services are billed by who?

A

The supervising PT

136
Q

Medicare and PTAs: PTAs may not do what?

A

They cannot provide eval services
Make clinical judgments or decisions
Or take responsibility for the service

137
Q

Medicare and PTAs: General supervision is required for all PTAs in all settings except ______ (which requires direct supervision)

A

PRIVATE PRACTICE

138
Q

“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??

A

True

139
Q

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

A

Balanced Budget Act

140
Q

Therapy Cap: Balanced Budget Act sole purpose was what?

A

To save resources needed to balance the federal budget

141
Q

Therapy Cap: Exceptions process:

Automatic exceptions for conditions IDed by CMS – refers to ___________

A

Processing of claims

142
Q

Therapy Cap Exceptions process: Uses of a _____ modifier

A

KX

143
Q

Examples of conditions likely to qualify for PT

A 
Joint replacement
Amputation
OA
Osteoporosis
Fracture
SCI
Head injury
Gait abnormality
144
Q

What does MACRA stand for?

A

Medicare Access and CHIP Reauth Act

145
Q

MACRA repealed what?

A

The flawed sustainable growth rate (SRG) formula

146
Q

MACRA further extended the ___________ exceptions process to 12/31/17

A

Medicare therapy cap

147
Q

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 _______

A

Fee for service

Quality
Improved outcomes

148
Q

With MACRA, CMS will determine which therapy services to renew by considering (3)

A

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

149
Q

Comprehensive Care Joint Replacement Model:

A

Medicare alternate payment model for elective HIP and KNEE jt replacement patients

150
Q

Comprehensive Care Joint Replacement Model: Payment is linked to _____ measurement and improved _________

A

Quality

Outcomes of care

Healthcare Delivery- JD (12 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions