Unit 2 Payment Across the Health Care Continuum

Question 1

How are visits to the Emergency Department billed to Medicare Part B?

Answer 1

-per service (fee for service) basis
-CPT codes
-physician fee schedule: list of fees that are used to pay doctors and healthcare providers

Question 2

Services in the Acute Care hospital are paid via:

Answer 2

-Inpatient prospective payment system (IPPS): predetermined, fixed amount associated with a pt’s diagnosis or classification adjust for severity
-paid per episode or “spell of illness”

Question 3

A patient’s Primary diagnosis determines assignment to a _________.

Answer 3

medical severity diagnosis-related group (MS-DRG)

Question 4

The DRG payment rate is adjusted based on age, sex, secondary diagnosis and major procedures performed.

Answer 4

primary diagnosis, co-morbidities, procedures, gender, age, discharge status other pts with same diagnosis

Question 5

DRG payment is paid how often?

Answer 5

per episode or “spell of illness”

Question 6

Medicare pays for _________ of hospital care per “spell of illness,” plus an additional lifetime reserve of ___________.

Answer 6

90 days; 60 days

Question 7

Define a single spell of illness:

Answer 7

begins when a pt has been admitted to the hospital or other facilities and ends when the pt has been discharged and has gone 60 days without being readmitted to hospital or other facility

Question 8

There is no limit on the number of spells of illness that Medicare covers

Answer 8

true

Question 9

Do the lifetime reserve days reset after each spell of illness?

Answer 9

no

Question 10

2023 Deductible and Copay for Medicare Part A beneficiaries
Inpatient Hospital Deductible $
Daily coinsurance for 61st-90th Day $
Daily coinsurance for lifetime reserve days $

Answer 10

-$1600
-$400
-$800

Question 11

Explain the Hospital Value-Based Purchasing Program:

Answer 11

-incentive payments for providing quality care, following best clinical practice, enhancing pt’s experiences

Question 12

Explain the Hospital Readmissions Reduction Program:

Answer 12

-penalties for poor quality measures
-reduce payments by 2% for excess readmissions
-readmitted within 30 days of discharge

Question 13

Explain the Hospital-Acquired Condition Reduction Program:

Answer 13

-penalties for poor quality measures
-1% payment reduction
-infections, falls, trauma, and wounds
-goal: improve pt safety and reduce HAC

Question 14

How can PTs have an impact on Acute Care Hospital Quality of Care?

Answer 14

-reduce hospital readmissions through enhancement of care transitions and discharge recommendations
-minimize pt harm events: pressure ulcers, falls, trauma
-improve pt satisfaction scores: set clean expectations for service delivery

Question 15

How is an LTACH paid and how are patients classified into payment groups?

Answer 15

-via the long-term hospital prospective payment system
-predetermined one-time lump sum based on the admitting diagnosis
-classified based on primary diagnosis with consideration of comorbidities, age, gender, procedures and discharge status of similar pts at that facility

Question 16

A Medicare beneficiary spent 10 days in an Acute Care Hospital before being transferred to an LTACH. What is the maximum number of days that this beneficiary will be fully covered by Medicare at the LTACH?

Answer 16

-covered under the 90 days of inpatient hospital care with an additional lifetime reserve of 60 days
-80 days + 60 days reserve

Question 17

How is an Inpatient Rehab Facility paid and how are patients classified into payment groups?

Answer 17

-via the IRF prospective payment system
-pre-determined payment for all goods and services provided during an IRF stay
-placed into a rehab impairment category based on primary admitting diagnosis; then placed into case mix group based on function, motor, and cognitive scores, and age; then placed into 1 of 4 tiers based on the pt’s comorbidities

Question 18

A Medicare Beneficiary spent 5 days in an Acute Care Hospital before being transferred to an Inpatient Rehab Facility. What is the maximum number of days that this beneficiary will be fully covered by Medicare at the LTACH?

Answer 18

-the first 60 days are fully covered (once deductible is met) if meets criteria including transfer from acute care hospital
-they are covered for the next 55 days

Question 19

For the same beneficiary, what happens on days 61-90?

Answer 19

they begin to pay a coinsurance

Question 20

What is the Medicare 60% compliance rule for IRF?

Answer 20

-requires that 60% of the facilities total patient population must meet one or more specified pathological conditions by CMS
-13 conditions: stroke, amputation, major multiple trauma, hip fracture, brain injury, neurological disorders, burns, SCI
-if facility does not meet this rule, the facility will be paid via the acute care hospital inpatient PPS

Question 21

What is the IRF-PAI used for?

Answer 21

-assess functional status, cognitive functions, impairments, medical conditions and comorbidities, and special services, treatments, and interventions
-IRF quality reporting

Question 22

What happens if an LTACH or IRF fails to submit their quality report annually?

Answer 22

-they will incur a 2% point reduction in annual payment update penalty

Question 23

What system is used to pay a SNF?

Answer 23

-SNF prospective payment system
-all inclusive rate determined at time they are admitted by assessment
-Medicare Administrative Contractor (MAC) processes Medicare claims

Question 24

What is the Minimum Data Set used for?

Answer 24

-determine the reimbursement (classification system)
-for Medicare part A

Question 25

The Payment Classification used in SNFs is called: _________________________________
oDetermined by 6 payment components (PT, OT, SLP, NTA, Nursing, Non-case mix component)
oBased on functional abilities on admission, comorbidities, and skilled nursing care needed

Answer 25

patient driven payment model

Question 26

How is Medicare’s payment to the facility adjusted starting on day 21 of a SNF stay?

Answer 26

there is a 2% decrease each week after day 20 up until say 100

Question 27

In order to be admitted to a SNF, a beneficiary must have a qualifying

Answer 27

3 night hospital stay

Question 28

Medicare Part A will cover up to ________ days per spell of illness, as long as a patient _____________________________

Answer 28

100; shows progress

Question 29

Medicare Part A will fully cover days ________________

Answer 29

1-20

Question 30

Starting on Day 21, the beneficiary must pay ____________________________________

Answer 30

the daily copay until day 100 ($200)

Question 31

Modes of Treatment
-Individual
-Concurrent
-Group
-Co-treatment

Answer 31

-Individual: treatment of 1 patient at a time
-Concurrent: treatment of 2 patients at the same time, when the pts are not performing the same or similar activities, regardless of the payer source, both of whom must be in line-of-sight of the treating therapist or assistant
-Group: treatment of 2-6 patients, regardless of payer source, who are performing the same or similar activities, and are supervised by a therapist or an assistant who is not supervising any other individuals
-Co-treatment: 2 clinicians from different disciplines treat 1 patient at the same time and perform different treatments (limited use; only appropriate for special circumstances-require complex intervention; support with documentation; not used to provide additional support

Question 32

What percentage of a patient’s total PT treatment time can be used for Concurrent AND Group Treatment?

Answer 32

25%

Question 33

If a CI and a student see two different patients at the same time, what mode of treatment can be billed?

Answer 33

concurrent

Question 34

Home Health
-Medicare Part A Coverage
-Medicare Part B Coverage

Answer 34

-Both: require homebound status and need for skilled care
-Part A: coverage after you are in hospital or SNF for at least 3 consecutive days as a hospital inpatient or Medicare-covered SNF stay; must receive home health services within 14 days of discharge; covers first 100 days per spell of illness
-Part B: covers care after the first 100 days; no hospital stay required; no deductible, coinsurance or copayment; DME (durable medical equipment) requires 20% coinsurance; unlimited coverage of home health visits if meet criteria

Question 35

A Home Health plan of care is based on a 60-day certification period. However, each “episode of care” lasts for _______________. What is used to determine how much a Home Health Agency is paid for each episode of care?

Answer 35

-30 days
-home health prospective payment system and patient driven groupings model; case mix adjustment (determined by admission source, primary diagnosis; functional impairment level, comorbidities)
-HHRG

Question 36

Do Medicare beneficiaries have cost-sharing for home health care services?

Answer 36

no, there is no deductible, coinsurance or copayment

Question 37

What is the maximum number of 30-day episodes of care?

Answer 37

there is no limit
-1st episode = early
=subsequent episodes = late

Question 38

What services are covered in the 30-day episode of care rate?

Answer 38

-all covered home health services (nursing and therapy services routine and non-routine medical supplies, home health care aid, and medical social services)
-excluded DME
-adjusts for beneficiaries with most expensive needs

Question 39

What is the OASIS and what is it used for?

Answer 39

-outcome and assessment information set
-pt specific, standardized assessment used to plane care, determine reimbursement and measure quality

Question 40

Who pays for DME?

Answer 40

under Medicare part B the pt has a 20% coinsurance for DME

Question 41

Who pays for palliative care? Is maintenance therapy covered for patients receiving palliative care?

Answer 41

Medicare part A covers all aspects of the pt’s care related to the terminal illness, including all services delivered by the interprofessional team, medication, medical equipment and supplies
-maintenance therapy is covered if documentation clearly supports the need for the PT services in order to prevent the decline of function

Question 42

What is the difference between routine and continuous care under the Medicare Hospice Benefit plan?

Answer 42

-routine: the beneficiary has elected to receive hospice care at his/her residence which can include private residence, assisted living facility or nursing facility
-continuous: care provided between 8-24 hours/day during periods of crisis to maintain the beneficiary at home to manage pain and other acute medical symptoms

Question 43

Outpatient Rehabilitation
Where are Medicare Part B services provided?

Question 44

How are outpatient PT services billed under Medicare Part B? What system is used?

Answer 44

-paid via restrospective payment system
-uses CPT codes and ICD-10 codes
-used physician fee schedule

Question 45

What is the time period for certification of the plan of care by the physician or nonphysician practitioner for outpatient PT services? How often does the plan of care need to be recertified?

Answer 45

-plan of care must be certified by a physician or non-physician practitioner within 30 days of initial PT visit
-changes in pt’s condition requires revision of long term goals; within 90 calendar days from date of initial visit; or if the plan of care has expired

Question 46

Discuss the following in Medicare Part B payment for therapy services:
oKX modifier:
oTargeted Medical Review:
oPayment for PTA services:

Answer 46

oKX modifier: states that continued therapy is medically necessary for the pt
oTargeted Medical Review: subject if amount billed is over $3000; facilities must submit documentation that support medical necessity for the services provided.
oPayment for PTA services: reduced payment for services provided by PTA that proceeds 10% of the treatment time(85% of service cost)

Question 47

What is the cost sharing for Medicare B beneficiaries?
oMonthly premium:
oDeductible:
oCoinsurance:

Answer 47

oMonthly premium: $164.90
oDeductible: $226
oCoinsurance: 20%

Question 48

Quality Payment Program:
*What is MIPS?
*What are Alternative Payment Models?

Answer 48

*merit-based incentive payment system: reporting system that looks at quality (outcome measures), improvement activities (fall risk assessments), advancing care information, and cost; mandatory for private practice PTs that meet a specific criteria based on number of beneficiaries they treat
*APM: a way to reward health care providers for providing quality care rather than volume; incentive payments for improving quality and reducing costs (eg. comprehensive care for joint replacement model)

Question 49

Define medical necessity and skilled care. Why is it important?

Answer 49

-medical necessity: determined by the licensed PT based on the results of a PT evaluation. services are provided for the purpose of preventing, minimizing, or eliminating impairments, activity limitations, and/or participant restrictions
-skilled care: increase the likelihood of one or more of the following goals: to improve function, minimize loss of function, or decrease risk of injury and disease
-Medicare Part B will only reimburse for PT services that are medically necessary

Question 50

What is the Advance Beneficiary Notice (ABN) form? When should it be issued?

Answer 50

-notifies a Medicare beneficiary that Medicare might not cover the services and there is possibility of having to pay for services out of pocket
-must be issues and signed before providing items of services the PT believes/knows Medicare may not cover, before providing items or services that Medicare usually covers but may not be considered medically reasonable and necessary for a particular Medicare beneficiary in a particular case, and before providing services that Medicare never covers
-can’t be issues after Medicare has denies a claim

Question 51

What is a Notice of Exclusion from Medicare Benefits (NEMB)?

Answer 51

states that the patient will be financially liable for the services he/she is about to receive
only given when the service is statutorily non-covered

Question 52

Can a clinic bill for services provided to a Medicare Part B beneficiary that were provided by a student? What are the requirements?

Answer 52

services are billable when the qualified practitioner is:
-recognized by the Medicare Part B beneficiary as the responsible professional within any session when services are delivered
-present and in the room for the entire session. student participated in the delivery of services when the practitioner is directing the service, making the skilled judgement, and is responsible for the assessment and treatment
-present in the room guiding the student in service delivery when the student is participating in the provision of services, and the practitioner is not engaged in treating another pt or doing other tasks at the same time
-responsible for the services and as such, signs all documentation

Question 53

Explain Medicare Part B rules/regulations for co-treatment.

Answer 53

-can’t bill separately for the same or different service provided to the same pt at the same time
-therapists must limit total billing time to the exact length of the session, so a therapist of one disciple may bill for the entire service or co-treating therapists of different disciplines may divide the service units
-therapists could only co-treat a pt when coordination between 2 disciplines benefits the pt
-documentation must clearly indicate the rationale for co-treatment and specific the goals each therapist will address through this method of intervention

Question 54

Discuss Medicare Part B rules/regulation for direct access to PT services in
*private practice:
*outpatient hospital settings:

Answer 54

*can go directly to PTs without a referral or visit to a physician; pt must be under the care of a physician; plan of care must be certifies by a physician or non-physician practitioner within 30 days of initial PT visit
*outpatient service may be ordered by a practitioner who is: responsible for the care of the pt; licensed in, or holds a license recognized in the jurisdiction where he/she sees the pt; acting within his/her scope of practice under state law; authorized by the medical staff to order the applicable outpatient services under a written hospital policy

Question 55

Discuss payment by private insurance for PT services provided via direct access.

Answer 55

-legal direct access to PT services doesn’t guarantee payment for services provided in the absence of a referral
-payment policy is determined by the insurer and is highly variable
-inaccurate to say that most insurance companies won’t pay for services without physician referral
-always verify individual coverage for each pt

Question 56

What are some of the different types of Cash Based Practices?

Answer 56

-all cash based (out-of-network providers)
-hybrid (cash + private insurances, cash + Medicare)
-mobile/concierge

Question 57

List the different places a Cash Based Practice can reside:

Answer 57

anywhere!
-mobile
-in home
-within a gym or fitness center (rent space)
-within other healthcare facilities
-a stand alone clinic

Question 58

How is payment received in a Cash Based Practice?

Answer 58

-all forms of payment: cash, check, credit, debit
-can also accept flexible spending accounts and health savings accounts
-all fee for service (determined by the PT, set own fees)
-2 options: individual sessions at time of service or programs paid in full at the first visit

Question 59

What is a SuperBill?

Answer 59

-a bill listing how much the patient paid for the therapy and all the ICD-10 codes, CPT codes and number of units for each code set to the insurance company as an out-of-network claim
-all PT documentation included

Question 60

Can Medicare Beneficiaries pay cash for PT services covered by Medicare?

Answer 60

No if a pt is a Medicare beneficiary, you must bill Medicare.
3 ways you can:
-non-participating provider can bill pt an extra 15%
-can issue ABN to the pt prior to providing services, you billed Medicare and they denied payment for the claim because the services were not considered to be reasonable and neccessary
-you are providing a service that is not normally covered by Medicare, such as wellness services

Question 61

Describe the 3 relationships a cash PT clinic can have with Medicare:
oNo Relationship:
oParticipating Provider:
oNon-Participating Provider:

Answer 61

oNo Relationship: do not treat any pts that are Medicare beneficiaries
oParticipating Provider: enroll in Medicare and agree to accept the Medicare approve reimbursement amounts for all services furnished to Medicare beneficiaries (based on current physician fee schedule)
oNon-Participating Provider: enroll in Medicare but do not agree to accept the Medicare approved reimbursement amounts in all cases. (Medicare pays 95% of physician fee schedule, can charge 15% above Medicare payment)

Question 62

What is a Limiting Charge?

Answer 62

a non participating provider can charge a Medicare beneficiary 15% above the Medicare payment fee

Question 63

What is the Mandatory Claims Submission Rule?

Answer 63

if a pt is a Medicare beneficiary, you must bill Medicare. they cannot pay cash. Also applies to pts with Medicare Advantage Plans

Question 64

How are School Based Services funded? Should parents pay for PT services in the educational setting?

Answer 64

-Medicaid
-state and local educational resources for allowable medical services delivered at school
-set my state
-should be no cost to the parent. third party funding should not be used all funding should fall under IDEA part B

Question 65

How are Early Intervention Services funded? What is the cost to parents?

Answer 65

-depends on state
-typically covered by Medicaid with parent consent, private insurance with parent consent
-free to parent except when federal or state law provided for a system of payments by families, including a schedule of sliding fees

Question 66

Quality measures are tools that measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include:

Answer 66

effective, safe, efficient, patient-centered, equitable, and timely care