Payment - Acute Care Hospital - Week 5

Question 1

EMERGENCY ROOM PAYMENT

Answer 1

• Per service (Fee for Service)
• use CPT codes

• Physician Fee Schedule
–> A list of fees that are used to pay doctors and healthcare providers

Question 2

ICU, CCU, PICU, ACUTE CARE PAYMENT


MEDICARE PART A

Answer 2

• Inpatient Prospective Payment System (IPPS)

• -> Predetermined, fixed amount associated with a patient’s diagnosis or classification adjusted for severity
• -> Paid per episode or “spell of illness”


• Medicare Severity Diagnostic Related Group (MS-DRG)
Based on:
⎯ Primary Diagnosis
⎯ Co-morbidities
⎯ Procedures
⎯ Gender
⎯ Age
⎯ Discharge status other patients with same diagnosis 

• Adjustments:
⎯ Severity of patient’s condition
⎯ Hospital’s case mix complexity (percentage of patients with more complex diagnoses) & costs incurred by the hospital

Question 3

“SPELL OF ILLNESS”

Answer 3

• Medicare pays for 90 days of any inpatient hospital care
• Plus an additional lifetime reserve of 60 days
• Unlimited number of “spells of illness”


Question 4

DRG payment is paid how often?

Answer 4

per spell of illness

Question 5

Do the lifetime reserve days reset after each spell of illness?

Answer 5

no

Question 6

2021 Deductible and Copay for Medicare Part A beneficiaries

Inpatient Hospital Deductable

Answer 6

$1,484 dring first 60 days

Question 7

2021 Deductible and Copay for Medicare Part A beneficiaries

Daily Coinsurance for Days 61-90

Answer 7

$371 until day 90

Question 8

2021 Deductible and Copay for Medicare Part A beneficiaries

Daily Coinsurance for lifetime reserve days

Answer 8

$742 per day

Question 9

How are visits to the Emergency Department billed to Medicare Part B?

Answer 9

Fee for service using CPT codes and the Physician Fee Schedule

Question 10

Hospital Inpatient Quality Reporting

Answer 10

PAY FOR PERFORMANCE:
MANDATORY REPORTING

• measured by Quality data metrics
–> can be charged fees for poor care

• Encourage hospitals & clinicians to improve quality & cost of inpatient care provided to all patients
• mandatory reporting drive quality improvement through measurement & transparency

Question 11

Hospital Value-Based Purchasing Program

Answer 11

PAY FOR PERFORMANCE:
INCENTIVE PAYMENTS

Incentive payments for:
• Providing quality care
• Following best clinical practices
• Enhancing patients’ experiences

Question 12

Hospital Readmission Reduction Program

Answer 12

PAY FOR PERFORMANCE:
PAYMENT REDUCTIONS

• charges hospitals fees for excessive readmission
• Reduce payments by 2% for excess readmissions
(penalties)
• Within 30 days of discharge

Question 13

Hospital-Acquired Condition (HAC) Reduction Program

Answer 13

PAY FOR PERFORMANCE:
PAYMENT REDUCTIONS

• encourages hospitals to improve patient safety and reduce number of conditions they may experience in hospital
• 1% payment reduction
• Infections, falls, trauma, & wounds
• Goal: improve patient safety and reduce HAC

Question 14

What can we do as PT to improve the quality of care in hospitals?

Answer 14

• Reducing hospital readmissions

• -> Enhancement of care transitions
• -> Discharge recommendations
• Minimize patient harm events: pressure ulcers, falls, trauma
• Improve patient satisfaction scores: set clear expectations for service delivery

Question 15

ACUTE CARE HOSPITAL:

PHYSICAL THERAPY BILLING

Answer 15

• Physical Therapy is paid from the pre-determined lump sum payment that the hospital gets from the Inpatient Prospective Payment System

• However, PTs use CPT codes to document their sessions
• -> To justify productivity
• -> To justify staffing needs

• Private Insurances
–> Out of pocket charges