Medicare Chapter 8

Question 1

The following criteria is a standard example of a requirement to be eligible for Medicare services:

Answer 1

Permanently disabled at age 55

Question 2

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.

Answer 2

Medicare Part B

Question 3

This part of Medicare covers outpatient prescription drug benefit for beneficiaries

Answer 3

Medicare D

Question 4

What is a a Prospective Payment System (PPS)?

Answer 4

A method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount.

Question 5

When looking at a SNF setting, what are the 6 payment components which add up to a beneficiaries daily rate?

Answer 5

OT Payment, PT Payment, SLP Payment, Nursing Payment, NTA Payment, Non Case-Mix Payment

Question 6

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.

Answer 6

Level II

Question 7

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”

Answer 7

Level I

Question 8

Medicare is the Interim?

Answer 8

Step in developing universal health insurance

Question 9

Three level of medicare?

Answer 9

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.

Question 10

Medicare Eligibility. Part A

Answer 10

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

Question 11

Medicare Eligibility. Part B

Answer 11

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.

Question 12

Part A: Acute and LTC; SNF

Answer 12

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)

Question 13

Part A: Acute and LTC

Answer 13

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

Question 14

Part A: SNF Benefits

Answer 14

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)

Question 15

Each resident is assessed using the RAI (resident Assessment Instrument)

Answer 15

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.

Question 16

What is a PPS

Answer 16

A perspective Payment System (PPS) is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount.

Question 17

Why the Patient Driver Payment Model (PDPM)

Answer 17

Goal is to focus on the patient getting the right skill that the patient needs.
Transitioning from Volume to Value

Question 18

Patient Driven Payment Model (PDPM)

MDS is completed on admission (and again on d/c)

Answer 18

I.D.s patient diagnosis and function

Question 19

With PDPM Payment for OT and PT will ?

Answer 19

Decrease slightly after day 20

Question 20

Beneficiaries Daily Rate

Answer 20

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.

Question 21

Skilled Services Medicare Part A

Answer 21

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.

Question 22

Treatment Minutes, Group Therapy; Medicare A

Answer 22

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

Question 23

Treatment minutes, group therapy, Medicare B

Answer 23

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.

Question 24

Treatment Minutes, Concurrent treatment

Answer 24

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

Question 25

Part A: Home Health Care Benefits

Answer 25

Qualify based on home confinement and need for skilled services (rehab or nursing)
MD must confirm homebound = cannot leave the home except for medical treatment or occasional community outing

Question 26

Home health care benefits: Hospice

Answer 26

Diagnose with terminal illness
Care service; nursing, social service, medicine, and counseling
Optional; OT and PT

Question 27

Rehabilitation hospital setting

Answer 27

three hour rule. Patient muse need 3 hr. of therapy 5 days a week to qualify

Question 28

Medicare Part B

Benefits

Answer 28

Pays for most of; profession services, outpatient, home health, DME, prosthetics, orthotics

Question 29

Skilled Services

Answer 29

Services shall be such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist or under the supervision of a therapist.

Question 30

Bipartisan Budget Act

Answer 30

Bill to increase spending limits, suspend the debt limit, and modify budget enforcement procedures

• Bipartisan Budget Act of 2018
• January 2020; services provided in whole or in party by assistant will received 5% of the applicable Part B payments
• Bipartisan Budget Act of 2019 passed no real impact on therapy.

Question 31

Four types of plans

Answer 31

Medicare HMO
Medicare PPOs
Private fee for service plans
Medicare special needs plans

Question 32

Medicare HMO

Answer 32

Most common form typically cost less than a traditional Medicare
Benefits only within the clan network

Question 33

Medicare PPOs

Answer 33

State wide or multi state network

Question 34

Private fee for service plans

Answer 34

Provide paid on per service basis
Higher out-of-pocket costs
Providers can charge 15% more

Question 35

Medicare special needs plans

Answer 35

New, for those with chronic or disabling conditions, living in institutions, or are Medicaid/Medicare

Question 36

Medicare Prescription Drug Benefit: Part D

Answer 36

Added in 2003, outpatient prescription drug benefit
Tow mechanisms stand-alone prescription drug plan or a plan to integrate into a Medicare advantaged alone prescription drug plan or a plan to integrate into a Medicare advantage.

Question 37

Quality and Medicare

Quality ensured through three processes

Answer 37

Provider certification
Provider must submit an application to Medicare
Certification ensures providers are license and meet minimum requirements
JCAHO for hospitals
Utilization review
Internal audit PT records – discuss POC, and make recommendations
External by QIOa

Question 38

Level I:

Answer 38

reviews the utilization pattern against a standard “edit”

Question 39

Level II:

Answer 39

a focused review by health professionals, review documentation to determine if care meets Medicare guidelines
May result in denial or referral to level III

Question 40

Level III

Answer 40

onsite review of patient documentation and billing records

Question 41

Fraud defined

Answer 41

making false statements or representations of material facts to obtain benefit or payment

Question 42

Abuse defined

Answer 42

any practice that is not consistent with the goals of providing pt with services that are medically necessary, meet professional standards, and are fairly priced