Medicare/Medicaid and Reimbursement in PT

Question 1

Medicare

Answer 1

Part of Social Security Act of 1965

Covers:
People over 65
Under 65 w/ certain disabilities
People of any age w/ permanent kidney failure

Question 2

Medicare Part A

Answer 2

All over 65 years old qualify @ no cost
Paid for by payroll deductions.

Costs:
FICA Payroll deduction
Hospital deductible –> $1260 for ea. benefit period, daily co-insurance of $315/day after 60days
DRG determines hospital payment.

SNF co-pays (for ea. benefit period) –> $0 for first 20days
$157.50/day for days 21-100
All costs/day after 100 days
Only inpatients.
Intended for rehab -> NOT long term
Propsective Payment System- payment determined by RUG level

Question 3

Medicare Part B

Answer 3

Optional insurance plan, monthly premium, deductible and co-pays.

Covers all expenses in hospital, may be @ lower rate than Part A.
Covers skilled therapy services in SNF.
Pt pays OOP for room and board in SNF.
Does have a therapy cap.

Costs:
Insurance premium: $104.90 /month
Deductible: $147 per year
Co-pay: 20% co-pay after deductible; patients often have supplemental insurance plan that covers this 20%.

Question 4

Medicare Part C & D

Answer 4

C: Medicare Advantage plans

D: Prescription drug coverage, monthly premium

*Supplemental insurance plans- monthly premium

Question 5

MN Health Care Programs: Medical Assistance

Answer 5

Est. 1965 through amendments to Social Security Act’MN residents who meet income and asset limits.
No monthly premium.
Joint program between federal & state govn’t; administered by counties.

Question 6

MN HC Programs: Minnesota Care

Answer 6

MN residents who meet income and asset limits.
(higher limits than Medical Assistance Program)
Monthly premium depends on family size & income
Max monthly premium is $50/month

Question 7

Centers for Medicare and Medicaid Services (CMS):

Answer 7

Regulate Medicare and Medical Assistance programs @ federal level.

Question 8

CMS Goals: Triple Aim

Answer 8

Lower health care costs
Improve health care quality
Deliver coordinated care

Question 9

CPT Codes

Answer 9

• Used to bill for services provided to patients.
• Uniform language for payers and research.
• Codes not provider specific.
• Timed and untimed codes
• Timed codes are in 15 min. increments.

Question 10

ICD-10 Codes

Answer 10

International Classification of Disease

• Used to assign codes to diagnoses
• Used for medical and treatment codes

Question 11

Medicare 8 Minute Rule

Answer 11

OP billing ofr medicare and MA patients.

Bill 15min. codes based on total time guidelines.

Question 12

MN 8 Minute Rule

Answer 12

OP billing for private insurance
IP billing for hospital, acute rehab, TCU

Based on time spent on each code.