Medicaid, Workers Comp, Doc & Legislation Flashcards
Medicaid Gen Facts
State/Fed health insurance program for ppl who have income below poverty line and/or have a disability. States admin program but receive at least 50% of funds form fed govt. Under ACA states are receiving increased fund. Includes fed mandated services and state optional services.
Mandated Medicaid Services Pre-ACA
Inpt/hospital, outpt/physician services, HHC, early periodic screening diagnosis & tx services for ppl 21 and less & services ID’ed as needed (like OT) must be covered, SNFs must provide skilled services to those who need them.
Optional Medicaid Services Pre-ACA
OT/PT/ST, DME, I practices, Targeted case mngt, prescription meds, dental care, eye glasses, crisis response services, pysch inpt for u21 & o65 & related services (like OT) in schools.
Medicare Changes Under ACA
MUST provide same minimum essential benefits that are provided in insurance exchanges: MH, sub abuse, behavioral health, rehab, habilitative, chronic, mngt services/devices & preventative/wellness services.
Medicaid Reform
D/t rapidly rising costs there is increase press for cost containment. Reform options could include: caps/other limits, reducing/eliminating optional benefits or managed care approaches.
Workers Comp
Funded jointly by individual employers or groups & state gov. Each state has a commission board to determine regulations, benefit provision, employ coverage & insurance admin. Employers can offer self-insuring. Coverage varies state to state & many states have cost-containment rules. WC includes cash/medical benefits
OTA Doc Guidelines
Qualified to write notes in medical charts & other formats. AOTA does not require cosigning but states might. Official docs are recommended to be cosigned
Eval/Re-eval Doc
Assessments admin/results, summary/analysis of findings, references to other pertinent reports & info. Occ therapy problem list & recommendations for OT tx, pt understanding of current status/subjective complaints & pts interest to participate in therapy
Tx Plan Doc
Prioritized prob list, goals related to probs - ST/LT goals written according to SMART, LTGs must indicate final desired fx’al outcomes, activites/tx procedures/methods, type, amt, frequency of tx, explanation of tx to pt & provision of statement of goals in pt words
Tx Implementation Doc
Activities, procedures & modalities used, pt response to tx toward goal attainment, goal modification in response to tx, change in anticipated goal complement time if needed, attendance/participation in tx w statement of reasons for missed tx, AE fabricated/issued w instructions for application/wear, pt related conferences/communication, home programs developed/taught & compliance
D/c Plan Doc
Sum of eval/intervention, compare initial & d/c status, specify # of sessions, goals met & fx’al outcomes, reasons for d/c, home programs to be followed, pt/fam edu, equipment provided/ordered, follow up plans/recommendations & referrals if needed
POMR
Prob Oriented Medical Record: system providing structure for progress note writing that is based on list of probs based on assessment. Includes SOAP notes: subjective, objective, assessment, plan
Consultation Reports
meetings/phone w other professionals, individual or caregiver
Critical Incident Reports
Significant, out of the norm events that may occur during OT eval/tx (ex: falls)
Diagnosis Codes
Describe persons condition or med reason for requiring services. Intern’l Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) most freq used in US. Updated annually so all must use latest version. Each service, procedure, supply or equipment must be realted to a ICD-9-CM code
Procedure Codes
Describe specific services provided by HC professionals. HCFA Common Procedure Coding System most commonly used (HCPCS), includes Physician Current Procedural Terms (CPT), also updated annually, each procedure, modality and tx should be coded.
G-Codes
7/1/13- outpt OT services must use. ID prim issue being addressed in therapy, modifiers are used to report persons impairment/limits/restrictions. Available to be used by all therapy disciplines so OTs can code for mobility, memory, swallowing & cognition. Used to track pt outcomes over time.
Medicare Prescription Doc
Req from physician w sig at bottom of note, an MD signed 700/701 form, sheet stapled w MD sig & statement “I cert that I approve of the attached tx plan.” Dx are acute not chronic, use onset dates of w/in 60 days of admission.
Medicare Tx Doc
Content must indicate tx shows level of complexity/sophistication or condition of pt must be of nature that req skilled therapist. Skilled rehab tx is mandatory- explain specific care needed* & notes must show therapeutic tx. Skilled care rendered must match dx & physician orders. Services must be unique to OT- no duplication, w HHC homebound status must be outlined Doc honestly but not over optimistically & provide behavioral observations, practical improvement should be noted w fx’al change- some improvement must be made wkly & services must be reasonable and necessary
Pt Protection & Affordable Care Act (ACA/Obama care)
Consists of 10 separate legislative titles that seek to improve accessibility, fairness, quality, efficiency, accountability and affordability of health insurance coverage in US.
Key Facts on HIPPA
Pt has right to access all records, does not exclude tx from occurring in groups, does not req guarantee of 100% confidentiality but req reasonable/vigilant safeguards, does not override state laws for further privacy & defers to state laws for minors.
Medicare Title 18-PL 89-97
Est Medicare & Supplemental Security Income (SSI)- enables pt w disability to receive monthly income
Rehab Act of 1973
Prohibits discrim on basis of disability in any program/activity receiving fed funds.
Fair Housing Act
Prohibits discrim on basis of disability, religion, sex, color race, nationality & familial status. Req that tenants be allowed to make reasonable accommodations using own $. Newly constructed multifam homes (4+) meet accessibility standards
OBRA of 1981
Omnibus Budget Reconciliation Act. Affirmed application of Sec. 504 of Rehab Act which prohibits discrim in fed funded programs to a diversity of services: headstarts, block grant, comm development. Provided Medicaid financing for comm-based services for ppl w ID/DD when services were determined to be less expensive than institutional care.
ADA
Americans w Disabilities Act: Prohibs discrim against qualified persons w disabilities in employment, transportation, accommodations, telecommunications & public services. Disabled criteria: phys/mental impairment that substantially limits 1(+) major life acts, persons having record of such impairment or person regarded as having such impairment. Actively using drugs, subs, gambling, kleptomania, pyromania or sexual behavior d/o NOT covered
ADA Title I- Employment
Prohibs employers from discrim against persons w disabilities in any aspect/phase of employment, allows questions about ones abilities but not specific to dx. Prohibs employment tests to screen out disabilities, person must be able to perform “essential fx’s” & “reasonable accommodations” must be provided by employees w 15(+) employees to persons w disabilities - unless cause undue Hardship
ADA Types of Reasonable Accommodations
Equipment, mods to exams/training materials/publications, provision of ancillary aids/services, modified schedules, job restructuring/reassignment, improvement of existing facilities to make accessible
ADA Ancillary Aids/Services
taped texts, qualified readers/other visual delivering materials, qualified interpreters/mods for hearing impairments, mod/acquisition of AE, other actions to increase accessibility
ADA Undue Hardship
Title 1: action that would sig difficult/overly expensive give financial resources of employer/size/major fx’s
Org exempt from ADA guidlines
US gov’t, Indian Tribes, and/or private tax-exempt membership clubs
ADA Title II
Public Services: Mandates State/local govts and departments may not descrim/exclude/deny ppl w disabilities participation/benefit from services: transportation, pub edu, employment, rec, social services, HC, courts, town meetings & voting
ADA Title III
Public Accommodations /Services Operated by Pub Entities: Mandates places of pub accommodation (hops, schools, dr offices, day care) may not discrim against ppl w disabilities. Pub places op-ed by private orgs must comply w accessibility standards: must be accessible, phys barriers removed, same are exempt. Private services that serve pub like movie theaters/restaurants cant discrim when givin services, pub/private trans systems must be accessible
TWIIA
Tix to work & work incentives improvement act: strives to make it more realistic/easier for persons w disability to work. Allowing pts w disabilities to maintain M/M HC benefits for 54mo after working. Estab comm-based voc planning & increases consumer choices for accessing employment **All state can design their own program
WIA
Work Investment Act: Estab federally sponsored nat’l employment/voc training system. “One-stop” delivery system for adults 18+ seeking employment training services. Core, intensive & training services. Receive ITA (individual training account) which is used to obtain services from any approved provider. transitional services offered for youth 14-21
ADA Title IV
Telecommunications: all TVs must have closed captioning, telephone co’s must provide telecommunication relay services to persons w hearing/speech impairs 24/7
Tech Related Assistance For Individuals w Disabilities Act
Funded dev of technology & tech aids 4 ppl w disabilities to improve comm, mobility, self-care, transportation & edu
Telecomm Act of 96
Req tele providers/manufactures to make services/equipment usable/accessible to ppl w disabilities if at all possible: cell phones, pagers, call waiting, caller ID & operator assistance
Child Abuse Prevention/Tx Act
Mandates professionals to report abuse/neglect.
EI & Edu Acts
Multiple acts have provided foundation for current EI/edu services. Include: FAPE 3-21, req that pub schools provide OT services to kids w SN if needed, designation of OT as prim tx service, funds for fam support services, recomm for states to develop EI progs w OT as prim tx
Re-authorization & Amendment of Individuals w Disabilities Act
Emp the purpose of IEP: to address childs unique needs as related to disability & decide how these needs can be served so the child has full access to the gen edu curriculum/participate in gen classroom. IEP can include AT/behavioral tx (OT contributor!), IEP planning team is open to related personnel at request of parent/school, edu student receives should prepare for I living & work. (Transition planning at age 14 [updated yrly] & transition services at 16). *Student MUST be invited to attend IEP. IEP students punished in same manner w disciplinary prevention measures stressed. IFSP for 0-2yrs
IDEA - 2004
Individuals w Disabilities Edu Improvement Act: directly addressed fx’al performance w academic performance.
NCLB Act
No Child Left Behind: gen edu law which emp standards-based edu. Considers OT to be pupil services personnel and sets not requirements for OT. Req schoolsto provide accommodations for mandated tests if needed- OTs can make recommendations
Age Discrim in Employment Act
prohibs discrim of workers 40+ & prohibs employers from setting retirement age
Freedom to Work Act
Amended in SS Act to enable Americans receiving reitrement SS benefits (65y/o) to be able to work w/o affecting income - no income restrictions
Omnibus Budget Reconciliation Act of 1990
Applied to all nursing homes that receive fed $ for M/M pts. Emp attending to resident rights, autonomy, self determination, providing quality of care & enhancing Q of L. Min Data Set (MDS): mandated comp resident assessment system admin at admission & the annually - coord by RN w OT contribution. Psychosoc/act pursuits patterns/physical/cog abilities must be considered - tx conditions must follow Resident Assessment Protocols (RAPs); restraint free environments emp, aims to guarantee that res have a right to choose how they want to receive care/live.
