Medicare Chapter 8 Flashcards
The following criteria is a standard example of a requirement to be eligible for Medicare services:
Permanently disabled at age 55
This part of Medicare covers outpatient, home health, durable medical equipment, prosthetics, and orthotics. Patients are responsible for 20% coinsurance rate under this part of Medicare.
Medicare Part B
This part of Medicare covers outpatient prescription drug benefit for beneficiaries
Medicare D
What is a a Prospective Payment System (PPS)?
A method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount.
When looking at a SNF setting, what are the 6 payment components which add up to a beneficiaries daily rate?
OT Payment, PT Payment, SLP Payment, Nursing Payment, NTA Payment, Non Case-Mix Payment
Considering the Utilization Review for fraud and abuse has three levels, the following describes this level: This is a focused review by health professionals, which includes reviewing documentation to determine if care meets Medicare guidelines.
Level II
Considering the Utilization Review for fraud and abuse has three levels, the following describes this level: This level is completed off site, by a third party. This level reviews the utilization pattern against a standard “edit”
Level I
Medicare is the Interim?
Step in developing universal health insurance
Three level of medicare?
Part A- provide coverage for inpatient hospital stays, shirt term rehab
Part B – Supplemental medical insurance, professional services (OT)
Medicaid – Extension to provide care to the poor.
Medicare Eligibility. Part A
Benefits based on payroll/premium contribution, age, marital status, or the presence of permanent disability
Most qualify based on Age (65) and a recorded of contribution for 40 quarts (10 years)
If no vested, may access Medicare after 65 and agreeing to pay a monthly premium
Under 65 if they have declared permanently disabled by the Social Security Administration for 24 months have end stage renal, or have ALS
Medicare Eligibility. Part B
Those eligible for premium free Medicate A are eligible for Med B
Part B is optional, most enroll in both
25% of Med B cost pain by enrollees
Monthly premiums vary by annual income and addition of drug benefit’s
$140 annual deductible and 20% coinsurance rate.
Part A: Acute and LTC; SNF
3 day minimum hospital stay to access benefits for SNF care
May be within 30 days of 3 days stay
Re-access if readmitted to SNF within 30 days
100 days per benefits period (may change if diagnosis changes)
Part A: Acute and LTC
Short stay acute hospital benefits for acute illness, disease, or surgical care
Recovery after hospital often in SNF, home with home health, or inpatient rehab
Those needing more than 25 days can receive care in a long-term care hospital
Hospitals prospective payment
1983 hospitals began PPS using case mix adjustments to predict resource utilization
Part A: SNF Benefits
Provides short term nursing and skilled rehab in a Medicate certified unit per benefit period.
Each resident is assessed using the RAI (resident Assessment Instrument)
Each resident is assessed using the RAI (resident Assessment Instrument)
3 parts Minimum Data Set (MDS)
- Comprehensive description of the status and problems of the resident
The care area assessment
Is triggered when there is a change in the MDS
Structured process by the care team to identify, analyze, address the problem.
The RAI utilization guidelines.
What is a PPS
A perspective Payment System (PPS) is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount.
Why the Patient Driver Payment Model (PDPM)
Goal is to focus on the patient getting the right skill that the patient needs.
Transitioning from Volume to Value
Patient Driven Payment Model (PDPM)
MDS is completed on admission (and again on d/c)
I.D.s patient diagnosis and function
With PDPM Payment for OT and PT will ?
Decrease slightly after day 20
Beneficiaries Daily Rate
There are 6 payment component which add up to the beneficiaries daily rate; OT, PT, SLP, nursing, non-therapy ancillary (mainly prescription drugs and supplies), Non- case mix (room and board and various capital costs)
The amount of services that each component provides has no effect on the fixed rate for reimbursement as the characteristic decide by MDS decide the reimbursement.
Skilled Services Medicare Part A
Required the skills of qualified technical or professionals health personnel
Must be provided directly by or under the general supervision of these skilled rehabilitation personnel
Must be provided on a daily basis with need met with inpatient care with a least 5 days a week
Services must be ordered by a physician.
Treatment Minutes, Group Therapy; Medicare A
Maximum of 4 patient per clinician
Participate in similar activities related to treatment goals
All minutes captured for each member
Maximum group minutes less than 25% of total treatment minutes during 7 day period
Treatment minutes, group therapy, Medicare B
Maximum of 4 patients per clinician
Participate in similar or different activities related to treatment goals
All minutes captured for each member
No restriction on total group minutes during 7 day period.
Treatment Minutes, Concurrent treatment
Therapist treat two or more patients at the same time
Med B- not allowed must be individual
Med A – if it is different task if same it is group time
