Reimbursement

Question 1

Who pays for OT services

Answer 1

Medicare
Medicaid
Private Insurance
Workers Comp program
Indian health services
military-veteran services

Question 2

What is Medicare

Answer 2

a health insurance program for those over 65 and eligible for social security

Question 3

What are Ot services covered under in medicare

Answer 3

part a and b

Question 4

Who monitors medicare

Answer 4

CMS

Question 5

What does part a cover

Answer 5

inpatient rehab
inpatient psy care
long term care
hospitals
SNFs
home health 
hospice

Question 6

Who are medicare part a facilities paid by

Answer 6

prospective payment system (PPS)

Question 7

What is PPS

Answer 7

Payment based on certain diagnoses or presenting problems

Question 8

What does part a cover in inpatient hospitals

Answer 8

90 days of hospitalization

After 60 days they need to copay

Question 9

What is the overall system of payment for inpatient hospitalization

Answer 9

PPS

Question 10

What helps categorize stays for inpt. hospitalization

Answer 10

DRGs (diagnositc related groups)

Question 11

What are the outcome measures for inpt rehab

Answer 11

IRF-PAI (payment assessment instrument)

FIM

Question 12

What is the rule regarding diagnoses in inpt. rehab

Answer 12

60% of admitted pts need to have 1 of the 13 diagnoses

Question 13

What is the 3 hr therapy rule in inpt rehab

Answer 13

people admitted must be able to tolerate 3 hrs of therapy per day

Question 14

What is inpt psy based on

Answer 14

ICD 10 codes (diagnosis is a big part of reimbursement in in pt. psy)

Question 15

When are pt.s admitted to long term care

Answer 15

w/in 60 days of being discharged to home from acute care

Question 16

How does payment occur in long term care facilities

Answer 16

DRG system

Question 17

How long must you be in long term care

Answer 17

25 days or more

Question 18

What are the requirements for benefits for SNF

Answer 18

Physician referral
3 day qualifying hospital stay
admit w/in 30 days
daily therapy requirements

Question 19

What are RUGS

Answer 19

resource utilization groups

something we est. payment categories based on number of min of therapy/week

Question 20

Wha are RUGS based on

Answer 20

minutes of therapy projected in a 7 day assessment period for a combination of OT,PT,ST

Question 21

What system uses RUGS

Answer 21

SNFs

Question 22

What do RUGS force the therapy team to do

Answer 22

disucss plan of care and be accountable for reimbursement

Question 23

What are the RUG levels

Answer 23

Ultra high 
Very high 
High
Medium 
Low

Question 24

What does ultra high consist of

Answer 24

720 min of therapy/week
at least 2 disciplines
one discipline 5x/wk
2nd discipline 3 days/wk

Question 25

What is the criteria for very high

Answer 25

500 min of therapy

at last 1 discipline 5 days/wk

Question 26

What is the criteria for high

Answer 26

325 min of therapy per week

1 discipline 5 days/week

Question 27

What is the criteria for medium

Answer 27

150 min per week

at least 5 days of therapy (any combo of the 3 therapies)

Question 28

What is the criteria for low

Answer 28

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

Question 29

Why do you need to know about your pt’s insurance

Answer 29

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

Question 30

Requirements for part a in home health

Answer 30

Homebound (can only leave for dr. appt and church)
Skilled therapy/certifications
100 visits per illness

Question 31

Who is the primary provider in home health

Answer 31

not ot

usually nursing or pt

Question 32

What do you fill out in home health for reimbursement

Answer 32

OASIS

Question 33

What is hospice

Answer 33

palliative care

Question 34

How many days can a person receive hospice

Answer 34

no limit