Reimbursement Flashcards
Who pays for OT services
Medicare Medicaid Private Insurance Workers Comp program Indian health services military-veteran services
What is Medicare
a health insurance program for those over 65 and eligible for social security
What are Ot services covered under in medicare
part a and b
Who monitors medicare
CMS
What does part a cover
inpatient rehab inpatient psy care long term care hospitals SNFs home health hospice
Who are medicare part a facilities paid by
prospective payment system (PPS)
What is PPS
Payment based on certain diagnoses or presenting problems
What does part a cover in inpatient hospitals
90 days of hospitalization
After 60 days they need to copay
What is the overall system of payment for inpatient hospitalization
PPS
What helps categorize stays for inpt. hospitalization
DRGs (diagnositc related groups)
What are the outcome measures for inpt rehab
IRF-PAI (payment assessment instrument)
FIM
What is the rule regarding diagnoses in inpt. rehab
60% of admitted pts need to have 1 of the 13 diagnoses
What is the 3 hr therapy rule in inpt rehab
people admitted must be able to tolerate 3 hrs of therapy per day
What is inpt psy based on
ICD 10 codes (diagnosis is a big part of reimbursement in in pt. psy)
When are pt.s admitted to long term care
w/in 60 days of being discharged to home from acute care
How does payment occur in long term care facilities
DRG system
How long must you be in long term care
25 days or more
What are the requirements for benefits for SNF
Physician referral
3 day qualifying hospital stay
admit w/in 30 days
daily therapy requirements
What are RUGS
resource utilization groups
something we est. payment categories based on number of min of therapy/week
Wha are RUGS based on
minutes of therapy projected in a 7 day assessment period for a combination of OT,PT,ST
What system uses RUGS
SNFs
What do RUGS force the therapy team to do
disucss plan of care and be accountable for reimbursement
What are the RUG levels
Ultra high Very high High Medium Low
What does ultra high consist of
720 min of therapy/week
at least 2 disciplines
one discipline 5x/wk
2nd discipline 3 days/wk
What is the criteria for very high
500 min of therapy
at last 1 discipline 5 days/wk
What is the criteria for high
325 min of therapy per week
1 discipline 5 days/week
What is the criteria for medium
150 min per week
at least 5 days of therapy (any combo of the 3 therapies)
What is the criteria for low
45 min therapy per week
at least 3 days of any combo of 3 therapies
2 or more nursing rehab services (restorative nursing) for 6 days/wk
Why do you need to know about your pt’s insurance
matters how we document only certain services may be covered how long/how many visits/how often for eval/reeval/progress may direct goals in network out of network services
Requirements for part a in home health
Homebound (can only leave for dr. appt and church)
Skilled therapy/certifications
100 visits per illness
Who is the primary provider in home health
not ot
usually nursing or pt
What do you fill out in home health for reimbursement
OASIS
What is hospice
palliative care
How many days can a person receive hospice
no limit
