Medicaid, Workers Comp, Doc & Legislation

Question 1

Medicaid Gen Facts

Answer 1

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.

Question 2

Mandated Medicaid Services Pre-ACA

Answer 2

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.

Question 3

Optional Medicaid Services Pre-ACA

Answer 3

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.

Question 4

Medicare Changes Under ACA

Answer 4

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.

Question 5

Medicaid Reform

Answer 5

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.

Question 6

Workers Comp

Answer 6

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

Question 7

OTA Doc Guidelines

Answer 7

Qualified to write notes in medical charts & other formats. AOTA does not require cosigning but states might. Official docs are recommended to be cosigned

Question 8

Eval/Re-eval Doc

Answer 8

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

Question 9

Tx Plan Doc

Answer 9

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

Question 10

Tx Implementation Doc

Answer 10

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

Question 11

D/c Plan Doc

Answer 11

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

Question 12

POMR

Answer 12

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

Question 13

Consultation Reports

Answer 13

meetings/phone w other professionals, individual or caregiver

Question 14

Critical Incident Reports

Answer 14

Significant, out of the norm events that may occur during OT eval/tx (ex: falls)

Question 15

Diagnosis Codes

Answer 15

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

Question 16

Procedure Codes

Answer 16

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.

Question 17

G-Codes

Answer 17

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.

Question 18

Medicare Prescription Doc

Answer 18

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.

Question 19

Medicare Tx Doc

Answer 19

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

Question 20

Pt Protection & Affordable Care Act (ACA/Obama care)

Answer 20

Consists of 10 separate legislative titles that seek to improve accessibility, fairness, quality, efficiency, accountability and affordability of health insurance coverage in US.

Question 21

Key Facts on HIPPA

Answer 21

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.

Question 22

Medicare Title 18-PL 89-97

Answer 22

Est Medicare & Supplemental Security Income (SSI)- enables pt w disability to receive monthly income

Question 23

Rehab Act of 1973

Answer 23

Prohibits discrim on basis of disability in any program/activity receiving fed funds.

Question 24

Fair Housing Act

Answer 24

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

Question 25

OBRA of 1981

Answer 25

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.

Question 26

ADA

Answer 26

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

Question 27

ADA Title I- Employment

Answer 27

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

Question 28

ADA Types of Reasonable Accommodations

Answer 28

Equipment, mods to exams/training materials/publications, provision of ancillary aids/services, modified schedules, job restructuring/reassignment, improvement of existing facilities to make accessible

Question 29

ADA Ancillary Aids/Services

Answer 29

taped texts, qualified readers/other visual delivering materials, qualified interpreters/mods for hearing impairments, mod/acquisition of AE, other actions to increase accessibility

Question 30

ADA Undue Hardship

Answer 30

Title 1: action that would sig difficult/overly expensive give financial resources of employer/size/major fx’s

Question 31

Org exempt from ADA guidlines

Answer 31

US gov’t, Indian Tribes, and/or private tax-exempt membership clubs

Question 32

ADA Title II

Answer 32

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

Question 33

ADA Title III

Answer 33

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

Question 34

TWIIA

Answer 34

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

Question 35

WIA

Answer 35

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

Question 36

ADA Title IV

Answer 36

Telecommunications: all TVs must have closed captioning, telephone co’s must provide telecommunication relay services to persons w hearing/speech impairs 24/7

Question 37

Tech Related Assistance For Individuals w Disabilities Act

Answer 37

Funded dev of technology & tech aids 4 ppl w disabilities to improve comm, mobility, self-care, transportation & edu

Question 38

Telecomm Act of 96

Answer 38

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

Question 39

Child Abuse Prevention/Tx Act

Answer 39

Mandates professionals to report abuse/neglect.

Question 40

EI & Edu Acts

Answer 40

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

Question 41

Re-authorization & Amendment of Individuals w Disabilities Act

Answer 41

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

Question 42

IDEA - 2004

Answer 42

Individuals w Disabilities Edu Improvement Act: directly addressed fx’al performance w academic performance.

Question 43

NCLB Act

Answer 43

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

Question 44

Age Discrim in Employment Act

Answer 44

prohibs discrim of workers 40+ & prohibs employers from setting retirement age

Question 45

Freedom to Work Act

Answer 45

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

Question 46

Omnibus Budget Reconciliation Act of 1990

Answer 46

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.