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Healthcare Delivery- JD > Lec 7: Other Paymenr For PT Workers Comp/PIP/Auto > Flashcards

Lec 7: Other Paymenr For PT Workers Comp/PIP/Auto Flashcards

1
Q

School based reimbursement: Part __ of individuals with Disabilities Education Act (IDEA) mandates education of children ages ____ who have a disability that interferes with education

A

B

3-21

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2
Q

School based reimbursement: What is an IEP

A

Individual Education Program

Written plan for each student
Parents an integral part of IEP

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3
Q

School based reimbursement: Services must be related to _____-

A

Education

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4
Q

Who pays? School based services?

A 
By school (district, state funds)
By Medicaid if eligible

HEALTH INSURANCE IS NOT RESPONSIBLE

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5
Q

What are some exceptions to school based services?

A

Injuries at school
School related injury

(School insurance to supplement health insurance)

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6
Q

Early intervention includes _______________

Part C- supports early intervention for _______ and _______ (what ages?)

Provided through what?

A

Individuals with Disabilities Education Act (IDEA)- federal law

Infants and toddlers (birth to age 3)

Through children’s individualized family service plan (IFSP)

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7
Q

Examples of specialized payers

A 
Guilds/unions
Religous groups
Specific causes (fundraisers)
Charitable groups- fund US travel for medical care
Private organizations
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8
Q

Workers Comp/Auto Insurance/PIP: Both provide ________ health coverage

A

LIABILITY

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9
Q

Workers Comp/Auto Insurance/PIP: laws and regulations vary from _______

A

State to state

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10
Q

Workers Comp: Is it state specific?

A

Yes

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11
Q

Workers Comp: State-specific liability coverage for health care costs as a result of an _________

A

Employed-related injury or condition

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12
Q

Workers comp: some states mandate participation in a ___________ program

A

State run

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13
Q

Workers comp: some states use codes other than ____

A

CPT

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14
Q

Workers comp coverage is typically excluded from

A

Health insurance coverage

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15
Q

Payers for workers comp care may include: (6)

A

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

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16
Q

Workers comp claims: provider must know individual _________ and ________ requirements to be paid for claims

A

State

Payer

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17
Q

Workers Comp Claims: Typically ______ of injury, not necessarily where care is provided

A

STATE

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18
Q

Workers Comp Claims: payment likely to be denied if _______

A

Requirements are not met

19
Q

State law requires that employers either have (2)

A

Workers comp insurance policy

Self insurance

20
Q

With workers comp insurance policy, premiums depend on what?

A

1) type of work
2) claims experience of employer
3) payroll

21
Q

With self insurance you need to apply and be approved by who?

A

Commissioner of the Dept of Banking and Insurance

22
Q

Law provides penalties for employers who do not have _____ coverage

A

Workers comp

23
Q

Explain the workers comp process (5)

A

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

24
Q

Auto Insurance: Auto liability covers damage to _________ including injuries to the _________

A

Vehicles in collisions

People involved

25
Q

Depending on auto insurance coverage, some policies will pay for ________ only and not injuries

A

Vehicle damage

26
Q

Auto Insurance: ______-specific liability for coverage of health care costs results from a MVA

A

State

27
Q

Auto Insurance: Health care coverage from MVA are typically ________ from health insurance coverage

A

Excluded

28
Q

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

A

PIP

29
Q

Auto Insurance: Does NJ have no-fault insurance?

A

Yes

30
Q

Auto Insurance: NJ – principle is to ensure that patient get needed care without waiting for _______________

A

Legal determinations of liability

31
Q

NJ Auto Insurance Law: Regulated under _______

A

NJ State Gov’t - Dept of Banking and Insurance

32
Q

NJ Auto Insurance Law: Specific regulations for PIP coding and billing –what kind of codes are used?

A

CPT codes

33
Q

NJ Auto Insurance Law: Regional ___________

A

Fee Schedules

34
Q

NJ Auto Insurance Law: ____ day notice requirement

A

21

35
Q

NJ Auto Insurance Law: What is the maximum daily allowable fee for physical medicine and rehab codes?

A

$105

36
Q

NJ Auto Insurance Law: There is a process to exceed max fee in ______ cases

A

Complex

37
Q

NJ Auto Insurance Law: PT requires _________ for PIP payment in NJ

A

MD referral

38
Q

NJ PIP: Highly regulated by the state due to ________ of auto insurance, _____ and ______

A

High cost
Fraud
Abuse

39
Q

NJ PIP: Mandates use of ________ specified in regulation for spine care (except for emergency care)

A

Care Paths

40
Q

NJ PIP: Regulations contain specific restrictions or exclusions for some ____, ______, ______

A

Procedures
Dx Tests
Treatments

41
Q

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 ________________

A

Standard form

Independent physical exam

42
Q

NJ PIP: Appeals process available for what?

A

Complex cases

43
Q

NJ PIP: APTAnj actively involved with DOBI in effort to ensure ________ for needed patient care

A

Proper payment

Healthcare Delivery- JD (12 decks)

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