Reimbursment Flashcards
HIPPA
(2008) Health insurance Portability & Accountability Act
(HIPPA) Establishes NPI
National Provider Identifier : 10 digit # used for billing
(HIPPA) Electronic Health Care transaction and code sets
Standard coding for documenting billing & diagnostic information
(HIPPA) Health information Privacy
Strengthened confidentiality information to minimum needed for intended purpose
(HIPPA) Security
Set standards for managing both electronic & paper information
Made standard billing codes required by insurance companies
ACA Obama Care
Patient Protection & Affordable Care Act
ACA Obama Care Overview
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
ACA Sample of Proposed Changes
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
Health Care Reform : Sample Changes (1)
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)
Health Care Reform : Sample Changes (2)
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
Health Care Reform : Sample Changes (3)
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
Before ACA ? (2010)
67% Private Health Insurance 13% Medicaid 12% Medicare 4% Military 15% No health insurance
Public Funded Programs : Medicare
Elderly or disabled
Funding by federal government
Participants pay a premium
PPS (prospective payment system) with retrospective review
Public Funded Programs : Medicaid
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.
Medicare Part A : Hospital Insurance Program
Hospital in pt. services In pt. rehab Psych hospital stays Hospice care SNF Inpatient stays Skilled Home Health
Medicare Part A : Hospital Inpatient PPS
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)
Medicare Part A : Hospital Inpatient PPS Facilitated
Utilization Review (LOS & Services)
Clinical Pathways
Care Managers
Push toward alternative level of care (d/c to SNF, Rehab, Home health)
Utilization Review
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.
Utilization Reviews : Typical Activities
Pre-admission certification
Mandatory 2nd opinion before surgery
Case manages to monitor care of a particular pt.
Clinical Pathways
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
Medicare Part A : Psych Hospitilization
DRG Exempt: paid on a per diem rate that covers all needed services based on statistics of each hospital costs
Medicare Part A : Hospice
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)
Medicare Part A : Inpatient Acute/Subacute Overview
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
Medicare Part A : Acute Rehab
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
Medicare Part A : SNF
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
Medicare Part A : Subacute Reab
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
Medicare Part A : Payment for SNF & Subacute
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)
Resident Assessment Instrument : MDS
Minimum Data Set
-screening of A core set of clinical and functional status elements
Resident Assessment Instrument : RUGS
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
Medicare Part A : Home Health Agency (HHA)
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
Medicare Part A : HHA Continued
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
Medicare Part B : Supplementary Medical Insurance Program
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
Durable Medical Equipment (DME)
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
Medicare Part C
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)
Medicare Part D
Prescription Plan
Medicare & OT
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
Medicare changes & AOTA
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)
Medicaid (1)
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
Medicaid (2)
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)
Program for All-Inclusive Care for the Elderly (PACE)
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
Other Public Funded Programs
Federal Employees Health & Benefit Program (FEHP) TRICARE Veterans program IDEA Workers Comp Indian Health Services Grant funded programs
Federal Employees Health & Benefit Program (FEHBP)
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
Department of Defense Health Care Programs : TRICARE
For active duty military
Services mostly provided at military health care facility and paid in full
Department of Defense Health Care Programs: Veterans Program
For honorably discharged military
Services can be provided outside of a VA facility but may incur greater cost to the individual
IDEA
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
Pediatric : Early Intervention
0-2 years State Health Dept. County coordinates Fee schedule by county Documentation must support self-help, adaptive behaviors.
Pediatric : Preschool
3-5 years State education department School district coordinates Fee schedule by county Documentation must have educational focus
School Age Pediatrics
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
Workers Compensation
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.
Workers Compensation (Continued)
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.
Private Health Insurance: Indemnity Plan
Traditional FFS (fee for service) 80/20
Few rules
Expensive
Private Health Insurance: HMO
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
Private Health Insurance : POS
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
Private Health Insurance: HDHP
High Deductible Health Plan
Members pay a high deductible but have 100% coverage for preventative; incentive to contain cost in pushed to the memebr
Private Health Insurance & OT
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
No Fault
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
Uninsured
% 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
