Reimbursement and Documentation

Question 1

What is HMO?

Answer 1

Health maintenance organizations

Question 2

What is PPO?

Answer 2

Preferred Provider Organizations

Question 3

What is POS?

Answer 3

point of service organizations

Question 4

What do system do hospitals use for payment?

Answer 4

Diagnostic Related Groups (DRG’s)

Question 5

What is the DRG System?

Answer 5

It is designed to pay hospitals a flat fee based on the patient’s diagnosis.

Question 6

PPO Characteristics?

Answer 6

• Can choose any provider in contracted list or out of network.
• No PCP required
• No referral Required
• Will receive a bill with % you are responsible for.

Question 7

What are the 6 requirements for workers Compensation?

Answer 7

• Medical Care
• Temporary Disability benefits
• Permanent Disability Benefits
• Supplemental Job displacement Benefits
• Vocational Rehab
• Death benefits

Question 8

What is Covered Under Medical Part B?

Answer 8

• Prosthetics
• Physical Therapy
• Physician Visits

Question 9

Define the 8 minute rule

Answer 9

1 Unit >= 8 Minutes and
<= 22 minutes

2 Units >= 23 Minutes and <= 37 minutes

3 Units >= 38 Minutes and
<= 52 minutes

4 Units >= 53 Minutes and
<= 67 minutes

Question 10

What are the 5 rehab RUG levels?

Answer 10

Low, Medium, High, Very High, Ultra High

Question 11

Characteristics of HMO?

Answer 11

• Limited Number of Providers
• Must be Contracted with the Insurance Company
• Agree to treat patients within the confines of the HMO guidelines
• Patient Selects Primary Care Physician (PCP)
• PCP works as “gate keeper” for referring treatment out
• Provides preventative care, immunizations, etc.
• If outside of their network, patient pays higher rate or whole bill

Question 12

What are the Requirements for Medicare?

Answer 12

-Over 65 Years Old or under 65 with a Permanent Disability. `

Question 13

Medicaid?

Answer 13

Medical Coverage for low income working families, some elderly or disabled individuals.

Question 14

Model of Treatment- Individual Treatment

Answer 14

When a student is treating only 1 patient. Supervising therapist cannot be engaged in any other activities or patient care.

Question 15

Model of Treatment- Concurrent Treatment

Answer 15

2 Patients being treated at the same time.

• Student treating 1 , Therapist treating 1
• Student treating 2, therapist not supervising other individuals or treating another patient.
• Therapist treating 2 patients, student not treating.

Question 16

Does Medicare Part B recognize concurrent treatment?

Answer 16

No, must be coded as group treatment.

Question 17

Model of treatment- Group Therapy

Answer 17

More than 3 patients being treated at once.

• Student leading group, therapist not reating or supervising others/
• Student is assisting therapist with group treatment.

Question 18

Explain medicare part A supervision requirement for students

Answer 18

The therapist needs to provide general supervision.

-Line of site supervision is required, but supervising therapist needs to determine appropriate level of supervision.

Question 19

Explain medicare part B supervision requirement for students

Answer 19

Therapist needs to direct student in providing the service.

-Therapist makes clinical decisions and is responsible for assessment and treatment.

Question 20

Will physical therapy aides be reimbursed under Part B

Answer 20

No. The Aide may assist with provision of therapy services (must be in line of site of therapist.