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Dwyer, Healthcare Management > Quiz 2 > Flashcards

Quiz 2 Flashcards

1
Q

Paying for end result and not Ind procedures

A

Paying for outcomes or value

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2
Q

Gold standard for PT

A

Functional status

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3
Q

Formula for value

A

Outcome/cost

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4
Q

Type of payment that was volume based and is provider centric

A

FFS

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5
Q

Type of sx that is value based and pt centric

A 
Outcome status (not FFS)
outcome status focuses on getting them better quick
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6
Q

Pqrs is what type of sx

A

P4r or pay for reporting

PQRS (physician quality reporting sx) is an example of pay for reporting

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7
Q

Value based is what type of sx

A

P4p

Pay for performance

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8
Q

What is impact act stand for

A

Improving Medicare post acute care transformation act

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9
Q

What are the principles of the impact act

A

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

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10
Q

Goals of impact

A

⦁ 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

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11
Q

PACs have a …… Day readmission measure policy

A

30 days

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12
Q

All PACs must reveal what 3 things in their documentation

A

Medicare spending
DC to community
Hosp rates of preventable readmins

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13
Q

What is care

A

Continuity assessment and recording and evaluation

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14
Q

Goal of CARE

A

To make a uniform assessment tool for all settings

To have common elements in those assessments

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15
Q

3 components of determining functional status

A

Global function
Regional function
Performance based

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16
Q

Quality assessment t vs quality assurance

A

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

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17
Q

What does the term comparative of the effectiveness of research mean

A

Comparing 1 TX to another

PT vs surgery

Looks at cost and effectiveness

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18
Q

Five things impacting customer satisfaction

A 
Communication
Consistency
Respect
Time
Understanding
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19
Q

Value based is what P4 sx

A

P4p

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20
Q

Functional limitation reporting is what p4 sx

A

P4r (pay for reporting)

FLR - G codes

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21
Q

G codes are what p4 sx

A

P4r
G codes are functional limitation reports specific to therapy services provided in ALL practice settings that do Part B Medicare

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22
Q

Explain g codes

A

All OP settings must use for therapy

Required on all claims otherwise no payment

Used for partB services

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23
Q

What are categories of gcodes or function limitation reports

A 
Mobility
Body position
Carrying or handling objects
Self care
 Other

mbcso

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24
Q

When are gcodes reported

A

Initial evaluation
Q ten TX days
Re eval
DC

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25
Q

FLRs are determined by using ____ and__Assessments

And must determine what

A

Valid and reliable

Must determine severity

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26
Q

4 functional assessment tools used in OP PT

A

Ampac
Foto
Optimal
Noms

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27
Q

FLR is used for what purpose with payers

A

Determines the value of services

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28
Q

What is Medicare antikickback statute

A

Prohibits knowingly and willfully getting or giving payment for referrals

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29
Q

if caught and prosecution is pursued, Who is responsible for kickback violations

A

Both parties

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30
Q

You could doup to……years for kickback violation

A

Five

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31
Q

Fraud could result in what three forms of punishment

A

Civil
Criminal
Admin

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32
Q

If a PTA uses your code and bills improperly who is liable

A

You

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33
Q

Any unrecieved service that was billed is known as

A

Fraud

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34
Q

Billing for equipment that was returned or using someone else’s info to Bill medicare are examples of

A

Fraud

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35
Q

What is triple damage

A

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

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36
Q

Civil penalties can go up to

A

11,000

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37
Q

Bipartisan act

A

Increases AMT of settlement for fraud up to 15400

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38
Q

What act is responsible for jail time for fraud against Medicare/Medicaid

A

Civil false claims act

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39
Q

What does focus on the Ind mean

A

Now fraud penalties will also go after the Ind as well

Civil and monetary

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40
Q

Where most fraud reports come from

A

Employees whistleblowing

Qui Tam Action - when the whistleblower can make $$

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41
Q

How much incentive can u get from whisleblowing

A

15-25%

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42
Q

These monitor rules and regs and look out for the company

A

Corporate compliance department

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43
Q

Omig

A

Office of Medicaid inspector general

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44
Q

IRS private inurement

A

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

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45
Q

IRS monitors tax exempt, HHS monitors…..

A

Kickbacks for referrals for Medicare and. Caid

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46
Q

What is stark II law

A

Prohibits referrals to own clinic where physician has ownerships

47
Q

Exception to stark law

A

physicians can rent clinic space to PT and PT has to carry out service (not a PTA or tech)

48
Q

Doing something stupid you weren’t supposed to do

Practicing out of your scope

A

Malfeasance

Mal did something she wasn’t supposed to

49
Q

Doing something stupid in general

Like US to the head

A

Misfeseance

50
Q

You should have done something but you did not

A

Non feasance

51
Q

Doing something wrong that you should know how to do right

A

Malpractice

52
Q

Intent to do harm or recklessness

A

Gross negligence

Intentional tort

53
Q

To be tried negligent they must prove what 4 things

otherwise you will not be guilty

A

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

54
Q

Most malpractice suits are

A

Unintentional tort DT negligenc

55
Q

What is flsa

A

Fair labor standards act

56
Q

Exempt vs. non exempt

A

Exempt is salàry non exempt is hourly

57
Q

There is less burden of proof with a….trial

A

Civil, these are prosecuted more

58
Q

Our standard of care

A

Guide to PT practice

59
Q

In liability, the seller is liable for all defective or harmful product regardless of

A

Fault

60
Q

Master is responsible for servant

Or hospital is responsible for nurse

A

Respondent superior

61
Q

Hospital is responsible for nurse regardless if the hospital was knowledgable or of her actions

A

Imputed knowledge

62
Q

Cut off for non exempt

A

7.25/he

63
Q

Eeoc

A

Equal opportunity employer act

Protects age

64
Q

This act allows men and women to have same wages

A

Equal pay act

65
Q

Fmla

A

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

66
Q

degree of health or recovery is ___

A

outcome

67
Q

FFS vs outcome based

A

FFS - thrived on more units (longer stay)

Outcomes based- quicker outcome, better outcomes

68
Q

the statute or clause that Medicare and Medicaid fraud are prosecuted under

A

civil false claims act

has both civil and criminal components

69
Q

failure to use care that a reasonably and prudent person would have done in the same circumstances

A

negligance

70
Q

in the 4 components of negligence (that have to be present in order to be found guilty) what encompasses “injury”

A

loss of income
medical expenses
loss of reputation
px and suffering

71
Q

are sick pay, severance pay, vacations, termination notice, lunch breaks a requirement by law in the work place

A

no

72
Q

what is Mark’s leadership formula for success

A

personally lead your career x (informally leading your peers + formally leading)

73
Q

1 attribute of a great manager

A

willingness to individualize

74
Q

components of pt care in regards to negotiation with insurer or case manager

A

SMART goals
focus on function
objective data
focus on DC

75
Q

a separate payment method that can be negotiated for high cost pts is called a

A

carve out

76
Q

in DFFS you want the copay to be ___

A

LOW

77
Q

with a capitated service you want copay to be ___

A

high

78
Q

in chapter 8 (marketing) he says to no longer call them pts, call them

A

consumers

79
Q

how is power shifting to the consumer (pts)

A

high deductibles
high copays
internet
rate my doctor sites

80
Q

what is ideal formula for a consumer

A

benefit exceeding cost

81
Q

what approach should you take as a work comp PT

A

sports med

82
Q

laws for work comp vary from ___ to ___

A

state to state

83
Q

with work comp pts we have to be very careful about what we say bc

A

there are multiple parties involved

often times the pt may have an attorney as well

84
Q

according to the speaker, one of the most important skills a work comp PT should have is

A 
negotiation skills
(we will negotiate with pts, referral sources, insurers, case manager)
85
Q

main diff btwn non work comp and work comp payment

A

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

86
Q

with work comp cases, time is truly

A

money

decisions must be made quick to get them back to work

87
Q

work comp goals must be

A

work specific and functional

88
Q

documentation with work comp has to be ___ and include___

A

OBJECTIVE

before and after comparison data

89
Q

one big difference in documentation with work comp cases

A

must be easily understood by all parties

jargon free

90
Q

work comp goals cannot be based on ___ or ___

A

pain or independence with HEP

must be objective towards their work function

91
Q

when is PT typically halted with work comp

A

when they are able to perform their work duty (even if other issues are occurring with them)

92
Q

what are some behavior differences you need to be sure you are documenting

A

inconsistent effort
unobserved px or performance that they say they experience but you don’t see
non compliance

93
Q

components of the occupational health management model

A 
Simplicity
Proximity
Immediacy
Centralization
Expectancy
94
Q

explain the simplicity component of the health management model

A

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)

95
Q

what is proximity component of the health management model

A

keep pt close to work env and duties
keep them engaged in the work place
use utensils and items from their work area

96
Q

what is expectancy component of the model

A

make compliance expectations clear

review their job description and know it well

97
Q

what description (used by work comp PTs) is more descriptive than a job description

A

physical demand analysis

these are performed by entities outside the company

98
Q

components of work comp objective reporting

A

specific
functional
objective
timely

99
Q

if recommendations are needed (for work comp) who do you make those to

A

the doc and the insurer (not the pt up front)

100
Q

what is work conditioning

A

replaced work hardening

where we can add aerobic conditioning and other simulation activities/exercises in addition to work comp

101
Q

progression of activity in work comp involves what 4 components

A

driven by work duties
therex -based on work
education - mechanics, erganomics
work conditioning

102
Q

with employee selection testing, employers test

A

every one applying, cannot pick and choose

103
Q

what is FCE

A

functional capacity evaluation
these are used to guide decisions made by case managers
extensive tests that can be EXPENSIVE

104
Q

results of an FCE can be used to

A 
put restrictions on employee
close case
determine a disability
determine different job/position placement
case manager decisions 
settlement
105
Q

how can PTs help with preventative measures

A 
PDA (physical demand analysis)
work station eval
onsite education
stretch and flex programs
corporate wellness programs
106
Q

work comp insurance vs casualty insurance

A

work comp -medical issues only

casualty - non medical issues

107
Q

what items must the impact act focus on (5)

A 
They must report on 
pt function (any changes)
 skin integrity 
meds
 falls and
 pt preferences
108
Q

What is IMPACT act

A

⦁ SNFs, IRFs, and LTCHs must begin reporting on quality measures by October 1, 2016 and HHAs by January 2017

109
Q

anytime you purchase or sell anything to a physician, always use

A

fair market value
be arms length (do contracts)
don’t “cut deals”

110
Q

claim form for all OP rehab facilities that states that your documentation is valid and accurate

A

CMS1500

111
Q

what is Civil False Claim Act

A

way in which medicare prosecutes fraud

112
Q

what is Qui Tam Action

A

whistleblowers making $$

113
Q

how many weeks off for FMLA

A

12

unpaid

114
Q

how many hours per week must you work for FMLA

A

24

Dwyer, Healthcare Management (2 decks)

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