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612 Management Exam 1 > Reimbursment > Flashcards

Reimbursment Flashcards

1
Q

HIPPA

A

(2008) Health insurance Portability & Accountability Act

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2
Q

(HIPPA) Establishes NPI

A

National Provider Identifier : 10 digit # used for billing

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3
Q

(HIPPA) Electronic Health Care transaction and code sets

A

Standard coding for documenting billing & diagnostic information

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4
Q

(HIPPA) Health information Privacy

A

Strengthened confidentiality information to minimum needed for intended purpose

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5
Q

(HIPPA) Security

A

Set standards for managing both electronic & paper information
Made standard billing codes required by insurance companies

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6
Q

ACA Obama Care

A

Patient Protection & Affordable Care Act

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7
Q

ACA Obama Care Overview

A

Expand health care coverage to 32 million low & middle income and those employed by small business at affordable cost
Original plan did NOT mention OT as a covered service

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8
Q

ACA Sample of Proposed Changes

A

Taxation of “cadillac” plans: those with NO co=pays or out of pocket expenses which have no personal incentive to limit costs.
Rewards to MDs for managing chronic illness
Phased out of Medicare Advantage Programs

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9
Q

Health Care Reform : Sample Changes (1)

A

More physician assistants and nurse practitioners providing primary care services
More control by individual states
-more pts. eligible for Medicaid
-Medical marketplace (2017) where affordable insurance can be purchased by individuals or small business owner (managed by the state)

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10
Q

Health Care Reform : Sample Changes (2)

A

Tax incentives to small business for those that provide employees access to insurance
Young adults up to 26 y.o. can stay on parents insurance
Adds free preventative services

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11
Q

Health Care Reform : Sample Changes (3)

A

No longer can bar from getting insurance or cancel insurance d/t catastrophic or chronic illness
Most Americans are required to get coverage or pay a penalty

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12
Q

Before ACA ? (2010)

A 
67% Private Health Insurance 
13% Medicaid 
12% Medicare 
4% Military 
15% No health insurance
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13
Q

Public Funded Programs : Medicare

A

Elderly or disabled
Funding by federal government
Participants pay a premium
PPS (prospective payment system) with retrospective review

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14
Q

Public Funded Programs : Medicaid

A 
Indigent or Catastrophic 
Funding Shared by state and federal 
Low fee for service 
Some providers refuse to accept or are not authorized to accept 
Hospitals have to accept medicaid pts.
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15
Q

Medicare Part A : Hospital Insurance Program

A 
Hospital in pt. services 
In pt. rehab 
Psych hospital stays 
Hospice care 
SNF Inpatient stays 
Skilled Home Health
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16
Q

Medicare Part A : Hospital Inpatient PPS

A

Prospective payment system
Rate per day is driven by level of service a particular hospital provides
Per episode rate covers all services including OT
Based on DRG (i.e. THR)

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17
Q

Medicare Part A : Hospital Inpatient PPS Facilitated

A

Utilization Review (LOS & Services)
Clinical Pathways
Care Managers
Push toward alternative level of care (d/c to SNF, Rehab, Home health)

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18
Q

Utilization Review

A

Primary tool of Managed Care Insurance but now used in most insurances
System to evaluate the necessity, appropriateness, and efficiency of use of services (most hospitals have a UR department)
Used to control over-utilization, reduce cost, and manage care.

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19
Q

Utilization Reviews : Typical Activities

A

Pre-admission certification
Mandatory 2nd opinion before surgery
Case manages to monitor care of a particular pt.

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20
Q

Clinical Pathways

A

Care plans developed to manage care of smiliar cases in a standard way
Example: Admission for hip replacement
-clinical pathway will trigger automatic orders: lab work, nsg care, prn pain meds
-Rehab ordered in a standard way
-i.e. Day 1: Pt. bedside for transfers and ambulation

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21
Q

Medicare Part A : Psych Hospitilization

A

DRG Exempt: paid on a per diem rate that covers all needed services based on statistics of each hospital costs

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22
Q

Medicare Part A : Hospice

A

Physician must certify the client is terminally ill
OT may only provide services to control symptoms or maintain ADL & basic functional skills (activity adaptation & adaptive equipment)

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23
Q

Medicare Part A : Inpatient Acute/Subacute Overview

A

TO be called a rehab facility they need to have a specific mix of conditions admitted
Generally payment is for 100 days or less unless extenuating circumstances

24
Q

Medicare Part A : Acute Rehab

A

Active therapy + 3 hour rule for eligibility.

  • Pt.’s admitted need active therapy from a minimum of two disciplines (OT, PT, SLP, Prosthetics) one must either be OT or PT
  • To be eligible for rehab pt. must be able to tolerate 3hrs of combined therapy 5 days per week
25
Q

Medicare Part A : SNF

A

Eligible first 100 days only id pt. needs SKILLED nsg (i.e. decubitis care) PT, OT, or SLP
Must recieve services at lease 5 days/week
Must have been hospitalized for a minimum of 3 days prior to admission to qualifiy

26
Q

Medicare Part A : Subacute Reab

A

Generally located in the SNF
Less strict than acute: three tiers of service with pay based on # of hours of therapy combined PT/OT/SLP
1-2 hrs of therapy per day

27
Q

Medicare Part A : Payment for SNF & Subacute

A

OT Part of daily rate:
-covers all needed services
-subacute pt.s are paid based on the level of therapy receiving based on min per day and min per week
Documentation : Resident Assessment Instrument (RAI) Includes:
MDS- Minimum data set (tells you where pt. level of A is)
RUGS- Resource Utilization group (# of min and what resources were used)

28
Q

Resident Assessment Instrument : MDS

A

Minimum Data Set

-screening of A core set of clinical and functional status elements

29
Q

Resident Assessment Instrument : RUGS

A

Resource Utilization Groups
based on ACTUAL performance
-OT often complete ADL portion
-Determine pt. complexity based on 53 levels & this determines billing rate
-includes monitor of mins of therapy/week

30
Q

Medicare Part A : Home Health Agency (HHA)

A

Eligibility based on need for skilled nursing PT or SLP
-OT covered only after qualifies for above skilled service
-once receiving OT can continue to do so even f other skilled services are no longer needed.
Therapist often do more than therapy
-monitoring BP, routine tx’s

31
Q

Medicare Part A : HHA Continued

A

Payment is provided based on a single rate for 60 days based on prediction of care needs upon completion of screening tool
Payment covers all services
-OASIS : Outcome & Assessment Information Set (documentation form)
-completed initally by PT, nsg, or SLP
-OT will provide input and may complete OASIS once active on case

32
Q

Medicare Part B : Supplementary Medical Insurance Program

A

Out pt. services (i.e. doctor visits, OT, PT)
OT treatment cost is based on current procedural terminology (CPT code)
-Docementation must reflect services is part of identified code chosen
-Must show improved function or safety
Annual deductible 80/20
-cap is about $1920 per year for OT/PT/SLP
Retrospective review d/t red flags

33
Q

Durable Medical Equipment (DME)

A

Includes devices that are used at home for medical necessity
-w/c, walker, hospital bed
-does not cover basic expenses for adaptive equipment (not seen as medically necessary)
Facility is requires to have a DME # in order to charge for DME equipment
-orthotic devices are not seen as DME except in private practice settings

34
Q

Medicare Part C

A

Medicare advantage
Alternative choice that covers both A & B
Managed care plan provided through private insurance
Results in lower cost to federal govt. & can provide some other benefits (dental, vision)

35
Q

Medicare Part D

A

Prescription Plan

36
Q

Medicare & OT

A

Requires current MD prescription & plan of care approved by physician
Requires a SKILL performed by an OT (not something an aid could do) & be performed by a qualified OT or OTA
Reasonable and necessary for the tx. of the identified illness or injury
-focused on improved safety or function

37
Q

Medicare changes & AOTA

A

Law requires that there is an opportunity for public comment prior to implementation
AOTA monitors and provides assistance in interpreting potential changes to its membership
AOTA lobbies for your benefit (be an AOTA member)

38
Q

Medicaid (1)

A

Regulated by each state (matching federal funds)

  • NY state eligibility (compared to Tx)
  • individual: income less than $9200/year -TX $2247
  • Family of 4: income less than $17,000’/year - TX $4630

Child Health Plus
Ny program to insure children
Aimed at those above medicaid level
Individual making up to $43,000 can get insurance for their children at a reduced sliding scale cost

39
Q

Medicaid (2)

A

Mandatory services
-i.e. hospitalization & SNF including OT, lab, xray
Optional Services
-Outpt. OT & Orthotics
-FFS (fee for service) with max total
-62% of states cover OT
-Many limit the amount of OT (# of visits, time period or types)

40
Q

Program for All-Inclusive Care for the Elderly (PACE)

A

For individuals who are eligible for both Medicare &Medicaid
These programs agree to provide all health care services to that individual for an annual fee from doctors visits o hospitalizations to nursing home admissions to home health in exchange for a monthly rate from both Medicare and Medicaid
PACE locally: Schenectady

41
Q

Other Public Funded Programs

A 
Federal Employees Health & Benefit Program (FEHP) 
TRICARE 
Veterans program 
IDEA 
Workers Comp 
Indian Health Services 
Grant funded programs
42
Q

Federal Employees Health & 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 visits that are often combined w/ other therapist
Strickly limited on # of therapy visits

43
Q

Department of Defense Health Care Programs : TRICARE

A

For active duty military

Services mostly provided at military health care facility and paid in full

44
Q

Department of Defense Health Care Programs: Veterans Program

A

For honorably discharged military

Services can be provided outside of a VA facility but may incur greater cost to the individual

45
Q

IDEA

A

Individuals w/ disavbilities education act (1990 &1997)
A free and appropriate education which emphasizes special education and related services to meet individual needs
Requires completion of Individual Education Plan (IEP) or Individual Family Service Plan (IFSP)
1998: Medicare Catastrophic Coverage Act
-allows school systems to bill Medicaid for services that are Medically Necessary

46
Q

Pediatric : Early Intervention

A 
0-2 years 
State Health Dept. 
County coordinates 
Fee schedule by county 
Documentation must support self-help, adaptive behaviors.
47
Q

Pediatric : Preschool

A 
3-5 years 
State education department 
School district coordinates 
Fee schedule by county 
Documentation must have educational focus
48
Q

School Age Pediatrics

A

5-21 years
State ed department
CSE coordinates (committee on special education)
Must have > 1 year delay
Documentation must be educationally based
May include medicaid funding

49
Q

Workers Compensation

A

Wage replacement benefits, medical tx, & vocational rehab.
Financed by individual employer and state
MTG = Medical tx. guidelines
-established for sh. back & knee
-other areas require prior approval
-MTG for Carpal Tunnel in review process
OTA’s & PTA’s cant treat pts.

50
Q

Workers Compensation (Continued)

A

Treatment must be focused on
-restoring function (goal: RTW w/in 6 mos.)
-focus on active not passive therapy
Must re-evaluate 2-3 weeks after 1st visit and 3-4 weeks there after. Max 8 weeks w/o variance request.

51
Q

Private Health Insurance: Indemnity Plan

A

Traditional FFS (fee for service) 80/20
Few rules
Expensive

52
Q

Private Health Insurance: HMO

A

Health Maintenance Organization
No claims for, wellness approach, cost containment
Gaitkeepers: Primary Care Physicians
-capitation: MD pair per member, prospective ammount
-early plans had incentives for staying below costs

53
Q

Private Health Insurance : POS

A

Point of Service: type of HMO that allows more member decisions of when to use out of network or to access specialist w/o first seeing primary care physician

54
Q

Private Health Insurance: HDHP

A

High Deductible Health Plan

Members pay a high deductible but have 100% coverage for preventative; incentive to contain cost in pushed to the memebr

55
Q

Private Health Insurance & OT

A

Often set fee that has been negotiated w/ billing department
Watch for limits on # of visits
Co-pays increasing
Fee per day regardless of service : one lump fee if receive OT & PT on the same day

56
Q

No Fault

A

Medical coverage related to a motor vehicle accident

  • no copay generous coverage
  • usually has a case manager checking in to assure services are reasonable and pt. is progressing
  • case manager may come to therapy visit
  • do need to check if client is no fault eligible
57
Q

Uninsured

A

% of working age adults uninsured
-2009 : 21%
-2014 : 13%
Majority are: young white men (with hispanics following) w/o a college diploma, who work full time in retail or wholesale trades for low wages

612 Management Exam 1 (5 decks)

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