Payment for occupational therapy services Flashcards
Medicare A
who is covered?
what is covered?
coverage for DME?
- People age 65 and older
- People under age 65 with black lung disease and permanent kidney failure
- People under age 65 with other long term disabilities
- People under age 65 who have received Social Security benefits for at least 24 month
- Covered for inpatient hospital stays and skilled nursing facilities if determined to be medically necessary by a patient’s physician
- Covered for home health care if medically necessary and the patient is home bound.
-DME is covered
Medicare B who is covered? what is covered? coverage for DME annual cap?
-Same as Medicare Part A. To receive Medicare Part B, people must enroll and pay a monthly premium.
- Unlimited services in a hospital outpatient clinic.
- Unlimited services as a part of a comprehensive home health care plan
- DME is covered if purchased from a Medicare participating provider. A physician’s prescription is required. Medicare Part B deductible and 20% co-pay apply. DME may be rented or purchased.
- services have an annual cap of $1,840 unless they are provided in a hospital outpatient clinic or through home health care.
Medicare Advantage Plans
who is covered?
what is covered?
coverage for DME
Same as Medicare Part A & B. People purchase Medicare coverage through a private insurance agency.
- Same as medicare part A and part B
- DME is the same as medicare part B
Medicaid
who is covered?
what is covered?
coverage for DME
- People of any age that are considered low income. Eligibility is determined by each state.
- People who are blind or disabled
- Rules regarding occupational therapy services vary from state to state. Providers must participate in Medicaid and accept Medicaid assignment.
- Basic DME is covered with a letter of medical justification and a Prior Approval form signed by the patient’s physician. DME must be cost effective.
Health Maintenance Organizations (HMO)
who is covered?
what is covered?
coverage for DME?
- Anyone who is eligible for coverage, enrolls in a plan, and pays the plan premiums.
- Services must be pre-certified by a case manager from the HMO.
- DME coverage is determined by individual plans. A physician’s prescription is required.
Preferred Provider Organizations (PPO)
who is covered?
what is covered?
coverage for DME?
- Anyone who is eligible for coverage, enrolls in a plan, and pays the plan premiums.
- annual limits may be placed on the number of sessions a person may have
- DME coverage is determined by individual plans. A physician’s prescription is required.
Point of Service Plans (POS)
who is covered?
what is covered?
coverage for DME?
- Anyone who is eligible for coverage, enrolls in a plan, and pays the plan premiums.
- Coverage is determined by individual plans, similar to HMO and PPO.
- DME coverage is determined by individual plans. A physician’s prescription is required.
Medicare Part A and part B
Appeals process
level 1,2,3,4,5,
Level 1 – redetermination by a Medicare Administrative Contractor (MAC)
Level 2 – Reconsideration by a qualified independent contractor (QIC)
Level 3 – Hearing before an Administrative Law Judge (ALJ)
Level 4 – Review by the Medicare Appeals Council
Level 5 – Judicial review in United States District Court
Level 1 – must be filed within 120 days of receipt of the initial determination
Level 2 – must be filed within 180 days of the MAC decision
Level 3 – must be filed within 60 days of the QIC decision
Level 4 – must be filed within 60 days of the ALJ decision
Level 5 – must be filed within 60 days of the Appeals Council decision
Medicaid
appeals process
- Providers may appeal a decision by Medicaid to deny or reduce services. The procedures vary by state.
- Procedures vary by state.
Treatments at Higher Risk for Denial of Payment
- Treatment for the same condition that has been provided past the third party payer’s pre-determined limitations.
- Maintenance therapy for a chronic condition
- treatment for a mental health condition
- third party payer considers expiremental
