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OTH Management > Reimbursement > Flashcards

Reimbursement Flashcards

1
Q

How do OTs get paid?

A

Reimbursement: monies from Patient Visits or Charges

Contracts to provide services elsewhere

Sales (equipment sales)

Tuition received for Continuing Education Offerings

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2
Q

Why do we need to know about reimbursement

A

Customer Satisfaction

Prevent Claim Denials

Accurate documentation of services

Prevent Fraudulent Claims

Job Security

Security of Our Profession

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3
Q

Established NPI
National Provider Identifier- 10-digit number

A

Identifies the practitioner who provided service
Get once start working
(connected to specific place of work)

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4
Q

Electronic Health Care transaction and code sets

A

standard coding for documenting billing and diagnostic information

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5
Q

What are the most common insurance?

A

Medicare and medicaid, employee funded and worker’s comp

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6
Q

Tricare is for

A

active duty military

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7
Q

IDEA

A

education mandate through education system

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8
Q

Deductible:

A

monies client pays out of pocket prior to being eligible for insurance coverage

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9
Q

Co-payment: aka co-pay:

A

set amount client pays for each visit

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10
Q

Co-insurance:

A

percentage client pays for services (often 20%)

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11
Q

Medicare

A

Elderly or Disabled

Funding by federal government

Participants pay premium

PPS (prospective payment system) with retrospective review

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12
Q

Medicaid

A

Indigent or Catastrophic

Funding Shared by state and federal
(state administers)

Low fee for service

Some providers refuse to accept or are not authorized to accept

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13
Q

Who can get medicare A

A

Hospital insurance program
inpatient rehab
inpatient services
hospice
psychiatric hospital
skilled nursing facility inpatient
skilled home health

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14
Q

What does Medicare Part B cover

A

Outpatient services
-Dr. and specialist
Doctor & specialist visits
Outpatient OT, PT, nutrition, psychology, etc
Outpatient testing

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15
Q

What does Medicare Part C cover

A

Managed Care Plan provided through private insurance (may charge additional premium)
Patient pays premium: covers A & B
may provide other benefits: dental, vision…

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16
Q

Medicare part D can cover

A

Prescriptions

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17
Q

What is the NY standard for medicaid

A

NY State eligibility (compared to Florida)
Individual: in NY eligible if income less than $18,755/year

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18
Q

Note: Federal Poverty Guide

A

1 person = $13,590 4 person =$27,750

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19
Q

Child Health Plus

A

NY Program to insure children
Aimed at those above Medicaid level
Individual making below $58,320 (maximum income level) can get insurance for their children at a reduced sliding scale cost

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20
Q

What are the mandatory services covered by Medicaid

A

Mandatory services covered
i.e., Hospitalization & SNF including OT, lab, x-ray

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21
Q

How does Medicaid pay

A

Number of visits, time period or types of conditions eligible, where provided (only at hospital outpatient)

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22
Q

PACE - Program for all-inclusive care for the elderly

A

For individuals who are eligible for both Medicare and Medicaid.

Program agrees to provide all health care services to that individual for an annual fee
From Doctors visits to hospitalizations to nursing home admissions to home health in exchange for a monthly rate from both Medicare and Medicaid.

PACE locally: Schenectady

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23
Q

Private Health Insurance

A

Employer funded or ACA purchased from Marketplace

Under 65-years-old mainly

Every company is different, but often follow Medicare’s recommendations and standards

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24
Q

What service of Medicare is this?

Substance abuse inpatient

A

Med A

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25
Q

What service of Medicare is this?

surgery for hip replacement?

A

Med A

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26
Q

What service of Medicare is this?

hospice care at home

A

Med A

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27
Q

What service of Medicare is this?

Skilled Nursing Home inpatient due to need for ventilator

A

Med A

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28
Q

What service of Medicare is this?

psyciatric hospitalization due to suicide attempt

A

Med A

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29
Q

What service of Medicare is this?
Substance abuse inpatient

A

Med A

30
Q

What service of Medicare is this?
Hospice care at home

A

Med A

31
Q

What service of Medicare is this?
outpatient hand

A

B

32
Q

What service of Medicare is this?
outpatient substance clinic

A

B

33
Q

What service of Medicare is this?
Dr. Office visit for upper resp infection

A

B

34
Q

What service of Medicare is this?

Copay made as an MVP patient for outpatient therapy for a medicare patient MVP

A

C

35
Q

What service of Medicare is this?

any services offered through CDPHP as a Medicare pt

A

C

36
Q

What service of Medicare is this?

prescription for lydex for use in outpatient therapt with ultrasound

A

D

37
Q

Outpatient OT services get paid by

A

Often a set fee negotiated with billing department for insurance company to pay

38
Q

What kind of copay does a pt pay for OT?

A

specialist

39
Q

Federal Employees Health and Benefit Program (FEHBP)

A

Services provided to active and retired federal employees

National model for health care reform

Administered in 350 different plans

Despite minimal coverage laws many have significant OT visit limits that are often combined with other therapies

40
Q

Department of defense healthcare

A

TRICARE Programs
For active duty military & family
Services mostly provided at military health care facility and paid in full

Veterans Program
For honorably discharged military
Services can be provided outside of a VA facility, but may incur greater cost to the individual

41
Q

Individuals with Disability Education Act (1980 & 1997)

A

Requires funding of services from the state and local funds including school taxes to provide:
free and appropriate education, which emphasizes special education and related services to meet individual needs

42
Q

Worker’s comp

A

Insurance for the worker injured ON the job

Includes:
Wage replacement benefits
Medical treatment
Vocational rehabilitation

Financed by individual employers and state

43
Q

Outpatient Worker’s comp

A

Treatment must be focused on
Restoring function (goal: RTW within 6 months)
Focus on active, not passive type therapy

Must re-evaluate 2-3 weeks after 1st visit and 3-4 weeks there after. Max 8 weeks without variance request.

44
Q

Worker’s comp MTG = Medical Treatment

A

Guidelines
Established for shoulder, back, knee, and Carpal Tunnel
Other areas require prior approval

45
Q

No Fault

A

Medical coverage related to a Motor Vehicle Accident
No copay, generous coverage

46
Q

Outpatient OT and No Fault

A

Case manager may attend therapy session:
checking in to assure services are reasonable and the patient is progressing

Verify by calling to see that client is
“No Fault” eligible

47
Q

Uninsured

A

Majority are: Young, white men (with Hispanic population following), without a college diploma, who work full time in retail or wholesale trades for low wages

48
Q

Percentage of working age adults uninsured
2009:
2014:
2022:

A

21%
13%
8%

49
Q

Billing can be based on:

A

Based on a formula of minutes provided or severity of patient diagnosis/condition

or

Flat rate for all rehab services in a given day (OT, PT, SLP)

50
Q

Common Procedural Terminology (CPT) Code

A

National based codes for treatments

51
Q

What is required to bill

A

ICD-10

52
Q

ICD-10 codes are

A

diagnosis codes

53
Q

International Classification of Diseases
Standard language created by

A

WHO

54
Q

Used in billing to describe patient’s condition

A

ICD-10

55
Q

Code used to describe condition

A

ICD-10

56
Q

Code used to describe a procedure (often surgical)

A

G-Codes

57
Q

Fee Schedule:

A

Our list of how much we hope to charge

58
Q

Often a negotiated or established charge with each given reimbursement agent (Medicare, CDPHP, Medicaid all have set payment schedules)

A

established fee schedule for outpatient services

59
Q

What do YOU think the OT manager has to consider when determining what to charge?

A

Time to complete
Level of complexity
Skill Required
Amount of direct supervision of the patient
Supply Expenses
Reimbursement Potential
Frequency of Services

60
Q

RVU: Relative Value Unit

A

Coded charge Dollar amount also based on Relative Value Unit

61
Q

HCPCS Codes

A

HCPCS = Healthcare Common Procedural Codes
Established in 1978

62
Q

in outpatient CPT codes are used for

A

direct billing

63
Q

iin in patient we still bill out codes but usually insurance companies aren’t going to see CPT codes meaning

A

used to demonstrate level of service provided

64
Q

Outpatient:
CPT codes

A

used for direct billing

65
Q

CPT Code: HCPCS Level I

A

Widely recognized by insurances and Medicare & Medicaid as standard coding

Time based codes: must pay attention to the minutes of therapy provided
therapeutic exercise, self care training, neuromuscular re-education

Service based codes: one unit no matter how much time it takes to complete
OT evaluation, splint fabrication, hot pack/cold pack

66
Q

DME: Hixpix: HCPCS Level IIDurable Medical Equipment

A

Includes devices that are used at home for medical necessity
Wheelchair, walker, hospital bed
Does not cover basic expenses for adaptive equipment (not seen as medically necessary)

67
Q

Purposes of Documentation

A

Chronological Record
legal list of what happened

Comply with Reimbursement
Medicare likes the words: function and safety

Communicate
call in sick…can someone pick up where you left off?

Clinical Reasoning
show you are providing a skilled OT service…if it looks like PT or looks like nursing or looks like Rec Therapy…guess who will be doing your job in the future!

Collect Data
Are you providing some quantitative demonstration of progress as well as qualitative?

Courtroom Defense
10 years from now can you or someone else tell what you did?

68
Q

Point of Service Documentation

A

Document while you provide care

69
Q

Reduce de-personalizing patient care during point of service documentation by:

A

Explaining why you are writing or typing so patient feels connected to what is happening

Pause writing when you are asking questions

Make eye contact while asking questions and for at least the beginning of the answer

70
Q
A

OTH Management (8 decks)

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