Quiz 2 Flashcards
Paying for end result and not Ind procedures
Paying for outcomes or value
Gold standard for PT
Functional status
Formula for value
Outcome/cost
Type of payment that was volume based and is provider centric
FFS
Type of sx that is value based and pt centric
Outcome status (not FFS) outcome status focuses on getting them better quick
Pqrs is what type of sx
P4r or pay for reporting
PQRS (physician quality reporting sx) is an example of pay for reporting
Value based is what type of sx
P4p
Pay for performance
What is impact act stand for
Improving Medicare post acute care transformation act
What are the principles of the impact act
All snfs, IRF, and LTCF must start reporting quality measures by 2016. They must report on pt function, skin integrity meds falls and pt preferences
Goals of impact
⦁ Payment should be based on patient needs, not site of service
⦁ Currently different payment systems for SNF, IRF, LTCH, and HHA
⦁ Payment should be better aligned with cost of care
⦁ Improved coordination of care
⦁ Improved quality
PACs have a …… Day readmission measure policy
30 days
All PACs must reveal what 3 things in their documentation
Medicare spending
DC to community
Hosp rates of preventable readmins
What is care
Continuity assessment and recording and evaluation
Goal of CARE
To make a uniform assessment tool for all settings
To have common elements in those assessments
3 components of determining functional status
Global function
Regional function
Performance based
Quality assessment t vs quality assurance
Assessment is measurement of quality as compared to a standard
Assurance is continued quality improvement, meaning it measures performances based on where we are now, where we are going and we’re we successful
What does the term comparative of the effectiveness of research mean
Comparing 1 TX to another
PT vs surgery
Looks at cost and effectiveness
Five things impacting customer satisfaction
Communication Consistency Respect Time Understanding
Value based is what P4 sx
P4p
Functional limitation reporting is what p4 sx
P4r (pay for reporting)
FLR - G codes
G codes are what p4 sx
P4r
G codes are functional limitation reports specific to therapy services provided in ALL practice settings that do Part B Medicare
Explain g codes
All OP settings must use for therapy
Required on all claims otherwise no payment
Used for partB services
What are categories of gcodes or function limitation reports
Mobility Body position Carrying or handling objects Self care Other
mbcso
When are gcodes reported
Initial evaluation
Q ten TX days
Re eval
DC
FLRs are determined by using ____ and__Assessments
And must determine what
Valid and reliable
Must determine severity
4 functional assessment tools used in OP PT
Ampac
Foto
Optimal
Noms
FLR is used for what purpose with payers
Determines the value of services
What is Medicare antikickback statute
Prohibits knowingly and willfully getting or giving payment for referrals
if caught and prosecution is pursued, Who is responsible for kickback violations
Both parties
You could doup to……years for kickback violation
Five
Fraud could result in what three forms of punishment
Civil
Criminal
Admin
If a PTA uses your code and bills improperly who is liable
You
Any unrecieved service that was billed is known as
Fraud
Billing for equipment that was returned or using someone else’s info to Bill medicare are examples of
Fraud
What is triple damage
How you are punished for fraud
Whatever you fraudulently billed Medicare, Medicare will make you pay 3 times that AMT plus your civil fees plus possible jail
Civil penalties can go up to
11,000
Bipartisan act
Increases AMT of settlement for fraud up to 15400
What act is responsible for jail time for fraud against Medicare/Medicaid
Civil false claims act
What does focus on the Ind mean
Now fraud penalties will also go after the Ind as well
Civil and monetary
Where most fraud reports come from
Employees whistleblowing
Qui Tam Action - when the whistleblower can make $$
How much incentive can u get from whisleblowing
15-25%
These monitor rules and regs and look out for the company
Corporate compliance department
Omig
Office of Medicaid inspector general
IRS private inurement
When the gov lets not for profit organization like hospitals to put money-back into their org for over all community benefit
But the IRS monitors to make sure no individuals are privately gaining those funds though money free education, free rent
IRS monitors tax exempt, HHS monitors…..
Kickbacks for referrals for Medicare and. Caid
What is stark II law
Prohibits referrals to own clinic where physician has ownerships
Exception to stark law
physicians can rent clinic space to PT and PT has to carry out service (not a PTA or tech)
Doing something stupid you weren’t supposed to do
Practicing out of your scope
Malfeasance
Mal did something she wasn’t supposed to
Doing something stupid in general
Like US to the head
Misfeseance
You should have done something but you did not
Non feasance
Doing something wrong that you should know how to do right
Malpractice
Intent to do harm or recklessness
Gross negligence
Intentional tort
To be tried negligent they must prove what 4 things
otherwise you will not be guilty
Duty of care
Breech of duty
Injury to pt
Cause
Cause means if u didn’t do what u did pt wouldn’t be Burt
Most malpractice suits are
Unintentional tort DT negligenc
What is flsa
Fair labor standards act
Exempt vs. non exempt
Exempt is salàry non exempt is hourly
There is less burden of proof with a….trial
Civil, these are prosecuted more
Our standard of care
Guide to PT practice
In liability, the seller is liable for all defective or harmful product regardless of
Fault
Master is responsible for servant
Or hospital is responsible for nurse
Respondent superior
Hospital is responsible for nurse regardless if the hospital was knowledgable or of her actions
Imputed knowledge
Cut off for non exempt
7.25/he
Eeoc
Equal opportunity employer act
Protects age
This act allows men and women to have same wages
Equal pay act
Fmla
You get 12 weeks unpaid leave and they cannot replace u
Must have worked there for a year and work at least 24 hrs a week
For births
Adoptions
Sickness Of
family or self
degree of health or recovery is ___
outcome
FFS vs outcome based
FFS - thrived on more units (longer stay)
Outcomes based- quicker outcome, better outcomes
the statute or clause that Medicare and Medicaid fraud are prosecuted under
civil false claims act
has both civil and criminal components
failure to use care that a reasonably and prudent person would have done in the same circumstances
negligance
in the 4 components of negligence (that have to be present in order to be found guilty) what encompasses “injury”
loss of income
medical expenses
loss of reputation
px and suffering
are sick pay, severance pay, vacations, termination notice, lunch breaks a requirement by law in the work place
no
what is Mark’s leadership formula for success
personally lead your career x (informally leading your peers + formally leading)
1 attribute of a great manager
willingness to individualize
components of pt care in regards to negotiation with insurer or case manager
SMART goals
focus on function
objective data
focus on DC
a separate payment method that can be negotiated for high cost pts is called a
carve out
in DFFS you want the copay to be ___
LOW
with a capitated service you want copay to be ___
high
in chapter 8 (marketing) he says to no longer call them pts, call them
consumers
how is power shifting to the consumer (pts)
high deductibles
high copays
internet
rate my doctor sites
what is ideal formula for a consumer
benefit exceeding cost
what approach should you take as a work comp PT
sports med
laws for work comp vary from ___ to ___
state to state
with work comp pts we have to be very careful about what we say bc
there are multiple parties involved
often times the pt may have an attorney as well
according to the speaker, one of the most important skills a work comp PT should have is
negotiation skills (we will negotiate with pts, referral sources, insurers, case manager)
main diff btwn non work comp and work comp payment
non work comp is consumer driven
work comp involves the pt needing to comply with recommendations
so in work comp, the pt isn’t the only customer
with work comp cases, time is truly
money
decisions must be made quick to get them back to work
work comp goals must be
work specific and functional
documentation with work comp has to be ___ and include___
OBJECTIVE
before and after comparison data
one big difference in documentation with work comp cases
must be easily understood by all parties
jargon free
work comp goals cannot be based on ___ or ___
pain or independence with HEP
must be objective towards their work function
when is PT typically halted with work comp
when they are able to perform their work duty (even if other issues are occurring with them)
what are some behavior differences you need to be sure you are documenting
inconsistent effort
unobserved px or performance that they say they experience but you don’t see
non compliance
components of the occupational health management model
Simplicity Proximity Immediacy Centralization Expectancy
explain the simplicity component of the health management model
you have to stay focused on the 1 prob
don’t chase subjective reports
pay attention to the MOI
(if pt. hurt shoulder, don’t add any focus to spine)
what is proximity component of the health management model
keep pt close to work env and duties
keep them engaged in the work place
use utensils and items from their work area
what is expectancy component of the model
make compliance expectations clear
review their job description and know it well
what description (used by work comp PTs) is more descriptive than a job description
physical demand analysis
these are performed by entities outside the company
components of work comp objective reporting
specific
functional
objective
timely
if recommendations are needed (for work comp) who do you make those to
the doc and the insurer (not the pt up front)
what is work conditioning
replaced work hardening
where we can add aerobic conditioning and other simulation activities/exercises in addition to work comp
progression of activity in work comp involves what 4 components
driven by work duties
therex -based on work
education - mechanics, erganomics
work conditioning
with employee selection testing, employers test
every one applying, cannot pick and choose
what is FCE
functional capacity evaluation
these are used to guide decisions made by case managers
extensive tests that can be EXPENSIVE
results of an FCE can be used to
put restrictions on employee close case determine a disability determine different job/position placement case manager decisions settlement
how can PTs help with preventative measures
PDA (physical demand analysis) work station eval onsite education stretch and flex programs corporate wellness programs
work comp insurance vs casualty insurance
work comp -medical issues only
casualty - non medical issues
what items must the impact act focus on (5)
They must report on pt function (any changes) skin integrity meds falls and pt preferences
What is IMPACT act
⦁ SNFs, IRFs, and LTCHs must begin reporting on quality measures by October 1, 2016 and HHAs by January 2017
anytime you purchase or sell anything to a physician, always use
fair market value
be arms length (do contracts)
don’t “cut deals”
claim form for all OP rehab facilities that states that your documentation is valid and accurate
CMS1500
what is Civil False Claim Act
way in which medicare prosecutes fraud
what is Qui Tam Action
whistleblowers making $$
how many weeks off for FMLA
12
unpaid
how many hours per week must you work for FMLA
24
