Payment For Services Terms & Medicare Flashcards
Capitation
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
Co-insurance
$ paid by pt; % of tot charge
Clinical/Critical Pathway
Standardized recommended tx protocol for specific dx
Deductible
Amt pt must pay provider before insurance benefits will pay
Diagnostic Related Groups (DRGs)
Descriptive categories established by CMS that determine the level of payment at a per case rate
Fee for Service
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%.
Health Insurance Marketplace
Created by ACA. Allows customers to compare cost of insurance plans in area. AKA HC exchanges.
HMOs
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.
Manages Care (MCO’s)
Include HMOs/PPO’s: Method of maintaining some control over cost/utilization of services while providing quality care.
Per diem
Negotiated, per day fee for services; SNFs & inpt
PPOs
Preferred Provider Org: similar to HMO but usually offers greater choice of providers-however as choices increase, % of payment decreases.
PPS
Protective Payment System; nationwide payment schedule that determines medicare payment for each inpt stay of a medicare beneficiary based on DRGs
3rd Party Payers
Orgs prim responsible for reimbursement for HC in US. HMOs/PPOs
TAR
Tx Authorization Request: Medicaid form of PCP must complete to doc the need for requested medically covered services & supporting rationale.
UCR
Usual & customary rate; ave cost of specific HC procedures in geographic area. Max amt insure will pay for a service/covered expense.
Fed Regs for Private Insurance Coverage: Must provide essential benefits to participants in their plan..
Under ACA; MH, sub abuse, behavioral health, rehab, habilitative, chronic, mngt services/devices & preventative/wellness services.
Fed Regs for Private Insurance Coverage
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
Medicare Gen Facts
Largest single payer for OT services, admin-ed by CMS, intermediaries determine if services provided are w/in Medicare guidelines.
Persons Eligible for Medicare Coverage
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
Medicare Part A
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).
Medicare Part B
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.
Medicare Criteria for Coverage of OT Services
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
Prim Diff Between Medicare A & B
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.
Medicare does NOT cover
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)
In 2013 the restorative potential of a person was determined to NOT be the sole payment criteria for skilled services…
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.
Medicare & Home Care
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
HHA reimbursement under Medicare
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
Medicare & OASIS
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
OTIP & Medicare
OT in I Practice: can be covered if Medicare certified OT & services are provided in office or pt home. Payment according to fee schedule.
Medicare & PHP
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
Medicare & DME
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.
Medicare Criteria for DME
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
