Lec 7: Other Paymenr For PT Workers Comp/PIP/Auto Flashcards
School based reimbursement: Part __ of individuals with Disabilities Education Act (IDEA) mandates education of children ages ____ who have a disability that interferes with education
B
3-21
School based reimbursement: What is an IEP
Individual Education Program
Written plan for each student
Parents an integral part of IEP
School based reimbursement: Services must be related to _____-
Education
Who pays? School based services?
By school (district, state funds) By Medicaid if eligible
HEALTH INSURANCE IS NOT RESPONSIBLE
What are some exceptions to school based services?
Injuries at school
School related injury
(School insurance to supplement health insurance)
Early intervention includes _______________
Part C- supports early intervention for _______ and _______ (what ages?)
Provided through what?
Individuals with Disabilities Education Act (IDEA)- federal law
Infants and toddlers (birth to age 3)
Through children’s individualized family service plan (IFSP)
Examples of specialized payers
Guilds/unions Religous groups Specific causes (fundraisers) Charitable groups- fund US travel for medical care Private organizations
Workers Comp/Auto Insurance/PIP: Both provide ________ health coverage
LIABILITY
Workers Comp/Auto Insurance/PIP: laws and regulations vary from _______
State to state
Workers Comp: Is it state specific?
Yes
Workers Comp: State-specific liability coverage for health care costs as a result of an _________
Employed-related injury or condition
Workers comp: some states mandate participation in a ___________ program
State run
Workers comp: some states use codes other than ____
CPT
Workers comp coverage is typically excluded from
Health insurance coverage
Payers for workers comp care may include: (6)
1) self insured companies paying own employees claims
2) third party admins contracted to manage self insured company claims
3) private workers comp carriers
4) state funded insurance company
5) contracted provider network with any of the above
6) federal govt for some federal employees
Workers comp claims: provider must know individual _________ and ________ requirements to be paid for claims
State
Payer
Workers Comp Claims: Typically ______ of injury, not necessarily where care is provided
STATE
Workers Comp Claims: payment likely to be denied if _______
Requirements are not met
State law requires that employers either have (2)
Workers comp insurance policy
Self insurance
With workers comp insurance policy, premiums depend on what?
1) type of work
2) claims experience of employer
3) payroll
With self insurance you need to apply and be approved by who?
Commissioner of the Dept of Banking and Insurance
Law provides penalties for employers who do not have _____ coverage
Workers comp
Explain the workers comp process (5)
1) Injured worker must file a claim (typically with employer)
2) Claim manager/case manager denies or approves claim
3) Preauth of care typically required
4) Coverage limited to work related Dx; NO COVERAGE FOR OTHER COMORBIDITIES
5) Balance billing of patient typically prohibited
Auto Insurance: Auto liability covers damage to _________ including injuries to the _________
Vehicles in collisions
People involved
Depending on auto insurance coverage, some policies will pay for ________ only and not injuries
Vehicle damage
Auto Insurance: ______-specific liability for coverage of health care costs results from a MVA
State
Auto Insurance: Health care coverage from MVA are typically ________ from health insurance coverage
Excluded
Auto Insurance: If the policy holder lives in a no-fault state, _______ coverage pays for medical expenses and lost wages for policy holder and policyholder’s passengers who are injured in an accident
PIP
Auto Insurance: Does NJ have no-fault insurance?
Yes
Auto Insurance: NJ – principle is to ensure that patient get needed care without waiting for _______________
Legal determinations of liability
NJ Auto Insurance Law: Regulated under _______
NJ State Gov’t - Dept of Banking and Insurance
NJ Auto Insurance Law: Specific regulations for PIP coding and billing –what kind of codes are used?
CPT codes
NJ Auto Insurance Law: Regional ___________
Fee Schedules
NJ Auto Insurance Law: ____ day notice requirement
21
NJ Auto Insurance Law: What is the maximum daily allowable fee for physical medicine and rehab codes?
$105
NJ Auto Insurance Law: There is a process to exceed max fee in ______ cases
Complex
NJ Auto Insurance Law: PT requires _________ for PIP payment in NJ
MD referral
NJ PIP: Highly regulated by the state due to ________ of auto insurance, _____ and ______
High cost
Fraud
Abuse
NJ PIP: Mandates use of ________ specified in regulation for spine care (except for emergency care)
Care Paths
NJ PIP: Regulations contain specific restrictions or exclusions for some ____, ______, ______
Procedures
Dx Tests
Treatments
NJ PIP: Decision point review process for procedures, dx testing, treatment to pre-certification – provider is required to use ___________ to submit to insurer.
Insurer may require a ________________
Standard form
Independent physical exam
NJ PIP: Appeals process available for what?
Complex cases
NJ PIP: APTAnj actively involved with DOBI in effort to ensure ________ for needed patient care
Proper payment
