Payment For Services Terms & Medicare

Question 1

Capitation

Answer 1

Payment system under which provider is paid prospectively a set fee for each member of a specific pop regardless if no covered health care is delivered. PMPM-per member per month. The healthier the enrollees the more the provider retains of the total PMPM payment

Question 2

Co-insurance

Answer 2

$ paid by pt; % of tot charge

Question 3

Clinical/Critical Pathway

Answer 3

Standardized recommended tx protocol for specific dx

Question 4

Deductible

Answer 4

Amt pt must pay provider before insurance benefits will pay

Question 5

Diagnostic Related Groups (DRGs)

Answer 5

Descriptive categories established by CMS that determine the level of payment at a per case rate

Question 6

Fee for Service

Answer 6

payment system under which the provider is paid the same type rate per unit of service. Traditionally payer pays 80% and pt/provider pays 20%.

Question 7

Health Insurance Marketplace

Answer 7

Created by ACA. Allows customers to compare cost of insurance plans in area. AKA HC exchanges.

Question 8

HMOs

Answer 8

Health Maintenance Org: most common form of mng-ed care. Maintains control over services by requiring enrollees to see only MDs w/in network & obtain referrals b4 specialty care.

Question 9

Manages Care (MCO’s)

Answer 9

Include HMOs/PPO’s: Method of maintaining some control over cost/utilization of services while providing quality care.

Question 10

Per diem

Answer 10

Negotiated, per day fee for services; SNFs & inpt

Question 11

PPOs

Answer 11

Preferred Provider Org: similar to HMO but usually offers greater choice of providers-however as choices increase, % of payment decreases.

Question 12

PPS

Answer 12

Protective Payment System; nationwide payment schedule that determines medicare payment for each inpt stay of a medicare beneficiary based on DRGs

Question 13

3rd Party Payers

Answer 13

Orgs prim responsible for reimbursement for HC in US. HMOs/PPOs

Question 14

TAR

Answer 14

Tx Authorization Request: Medicaid form of PCP must complete to doc the need for requested medically covered services & supporting rationale.

Question 15

UCR

Answer 15

Usual & customary rate; ave cost of specific HC procedures in geographic area. Max amt insure will pay for a service/covered expense.

Question 16

Fed Regs for Private Insurance Coverage: Must provide essential benefits to participants in their plan..

Answer 16

Under ACA; MH, sub abuse, behavioral health, rehab, habilitative, chronic, mngt services/devices & preventative/wellness services.

Question 17

Fed Regs for Private Insurance Coverage

Answer 17

Under ACA: insurers can no longer refuse coverage to ppl w per-existing conditions, insurers cannot raise interest/premiums based on occ, gender, pre-existing condition, health status or claim hx. Must allow young adults until 26 under parents if covered as dependents & Insurers cannot set caps on annual/lifetime coverage

Question 18

Medicare Gen Facts

Answer 18

Largest single payer for OT services, admin-ed by CMS, intermediaries determine if services provided are w/in Medicare guidelines.

Question 19

Persons Eligible for Medicare Coverage

Answer 19

Ppl 65+; ppl w end stage renal disease/permanent kidney failure that may req dialysis/kid transplant; ppl w lT disabilities (ALS/MS) who have received gov’t funded disability benefits for 24mo may be eligible

Question 20

Medicare Part A

Answer 20

Pays for inpt, SNF, HHC, rehab & hospice (term ill, less than 6mo to live). Automatically provided to all who are covered by SS & meet above criteria. Services provided in acute care receive prospective/predetermined rate on DRGs-covers all services including OT. Covered services have specific time limits & also req deductible/co-insurance payments by beneficiary (annual deductible/HHC 20% payed by pt).

Question 21

Medicare Part B

Answer 21

Pays for outpt physical & other professional services inc OT provided by I practitioners. Considered Supplemental Insurance & must be purchased by beneficiary at monthly premium. No specific time limit & have 20% co-payment.

Question 22

Medicare Criteria for Coverage of OT Services

Answer 22

Prescribed by physician/furnished according to physician-approved plan of care. Performed by qualified OT/OTA w S. Service is reasonable/necessary for tx of dx. No diagnositic restrictions for coverage. OT must result in signif/practical improvement of fx’ing

Question 23

Prim Diff Between Medicare A & B

Answer 23

Frequency in which pt receives services. Inpt A req services for a min of 5days per wk. Part B typically covers 3 days per wk outpt services.

Question 24

Medicare does NOT cover

Answer 24

Most chronic illnesses, LT supportive care or medical expenses incurred when ill. OT in SNF is covered if pt req skilled nursing/rehab daily (5x/wkly)

Question 25

In 2013 the restorative potential of a person was determined to NOT be the sole payment criteria for skilled services…

Answer 25

Services to prevent/slow deterioration & maintain person at highest level of fx must be recog as skilled - covered if reasonable/necessary. If can be performed by non-skilled person, its not covered.

Question 26

Medicare & Home Care

Answer 26

Covered if person is home bound & needed intermittent skilled nursing care, PT or ST before OT began. Homebound criteria: “confined” d/t AD, assistance of others or special transportation; if person leaves it requires “considerable/taxing effort,” & may leave for medical appts and non-med short/infrequent appts like hair/church

Question 27

HHA reimbursement under Medicare

Answer 27

PPS. This rate per episode system applies to all HH services inc all forms of therapy/med supplies. DME excluded. PPS uses HH Resource Groups (HHRGs) to determine pay rate. Episode=60day beginning w first payable visit and ending 60 days after start of care

Question 28

Medicare & OASIS

Answer 28

Initial assessment visit/comprehensive assessment using Outcome & Assessment Info Set must be completed to verify eligibility for Medicare HH benefits, cont need for HHC & plan for nursing, medical, social, rehab & d/c needs.
OT Can complete initial OASIS need for OT establishes program eligibility - initial assessment must be completed w/in 48hrs of referral/return home. OT can conduct follow up, transfer & d/c evals. **OT is NOT an initial qual service for HHC

Question 29

OTIP & Medicare

Answer 29

OT in I Practice: can be covered if Medicare certified OT & services are provided in office or pt home. Payment according to fee schedule.

Question 30

Medicare & PHP

Answer 30

Partial Hospitalization Program; services in hosp-affiliated or comm MH psych day program. Covered under general Medicare guidelines w prescription, reasonable/necessary & fx expected to improve. -not soc/rec/diversional cover

Question 31

Medicare & DME

Answer 31

Rental/purchase expenses for DMA are covered if used in home. & necessary/reasonable to treat illness or injury. MD prescription needed & must include dx, prognosis & reason for DME.

Question 32

Medicare Criteria for DME

Answer 32

Repeated used can be withstood, prim/customarily used for medical purpose, gen not useful to a person in absence of dx. Self help items: grab bars, RTS not reimbursable because others use them and not considered medically necessary