Unit 2 Payment Across the Health Care Continuum Flashcards
How are visits to the Emergency Department billed to Medicare Part B?
-per service (fee for service) basis
-CPT codes
-physician fee schedule: list of fees that are used to pay doctors and healthcare providers
Services in the Acute Care hospital are paid via:
-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”
A patient’s Primary diagnosis determines assignment to a _________.
medical severity diagnosis-related group (MS-DRG)
The DRG payment rate is adjusted based on age, sex, secondary diagnosis and major procedures performed.
primary diagnosis, co-morbidities, procedures, gender, age, discharge status other pts with same diagnosis
DRG payment is paid how often?
per episode or “spell of illness”
Medicare pays for _________ of hospital care per “spell of illness,” plus an additional lifetime reserve of ___________.
90 days; 60 days
Define a single spell of illness:
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
There is no limit on the number of spells of illness that Medicare covers
true
Do the lifetime reserve days reset after each spell of illness?
no
2023 Deductible and Copay for Medicare Part A beneficiaries
Inpatient Hospital Deductible $
Daily coinsurance for 61st-90th Day $
Daily coinsurance for lifetime reserve days $
-$1600
-$400
-$800
Explain the Hospital Value-Based Purchasing Program:
-incentive payments for providing quality care, following best clinical practice, enhancing pt’s experiences
Explain the Hospital Readmissions Reduction Program:
-penalties for poor quality measures
-reduce payments by 2% for excess readmissions
-readmitted within 30 days of discharge
Explain the Hospital-Acquired Condition Reduction Program:
-penalties for poor quality measures
-1% payment reduction
-infections, falls, trauma, and wounds
-goal: improve pt safety and reduce HAC
How can PTs have an impact on Acute Care Hospital Quality of Care?
-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
How is an LTACH paid and how are patients classified into payment groups?
-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
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?
-covered under the 90 days of inpatient hospital care with an additional lifetime reserve of 60 days
-80 days + 60 days reserve
How is an Inpatient Rehab Facility paid and how are patients classified into payment groups?
-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
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?
-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
For the same beneficiary, what happens on days 61-90?
they begin to pay a coinsurance
What is the Medicare 60% compliance rule for IRF?
-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
What is the IRF-PAI used for?
-assess functional status, cognitive functions, impairments, medical conditions and comorbidities, and special services, treatments, and interventions
-IRF quality reporting
What happens if an LTACH or IRF fails to submit their quality report annually?
-they will incur a 2% point reduction in annual payment update penalty
What system is used to pay a SNF?
-SNF prospective payment system
-all inclusive rate determined at time they are admitted by assessment
-Medicare Administrative Contractor (MAC) processes Medicare claims
What is the Minimum Data Set used for?
-determine the reimbursement (classification system)
-for Medicare part A
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
patient driven payment model
How is Medicare’s payment to the facility adjusted starting on day 21 of a SNF stay?
there is a 2% decrease each week after day 20 up until say 100
In order to be admitted to a SNF, a beneficiary must have a qualifying
3 night hospital stay
Medicare Part A will cover up to ________ days per spell of illness, as long as a patient _____________________________
100; shows progress
Medicare Part A will fully cover days ________________
1-20
Starting on Day 21, the beneficiary must pay ____________________________________
the daily copay until day 100 ($200)
Modes of Treatment
-Individual
-Concurrent
-Group
-Co-treatment
-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
What percentage of a patient’s total PT treatment time can be used for Concurrent AND Group Treatment?
25%
If a CI and a student see two different patients at the same time, what mode of treatment can be billed?
concurrent
Home Health
-Medicare Part A Coverage
-Medicare Part B Coverage
-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
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?
-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
Do Medicare beneficiaries have cost-sharing for home health care services?
no, there is no deductible, coinsurance or copayment
What is the maximum number of 30-day episodes of care?
there is no limit
-1st episode = early
=subsequent episodes = late
What services are covered in the 30-day episode of care rate?
-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
What is the OASIS and what is it used for?
-outcome and assessment information set
-pt specific, standardized assessment used to plane care, determine reimbursement and measure quality
Who pays for DME?
under Medicare part B the pt has a 20% coinsurance for DME
Who pays for palliative care? Is maintenance therapy covered for patients receiving palliative care?
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
What is the difference between routine and continuous care under the Medicare Hospice Benefit plan?
-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
Outpatient Rehabilitation
Where are Medicare Part B services provided?
How are outpatient PT services billed under Medicare Part B? What system is used?
-paid via restrospective payment system
-uses CPT codes and ICD-10 codes
-used physician fee schedule
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?
-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
Discuss the following in Medicare Part B payment for therapy services:
oKX modifier:
oTargeted Medical Review:
oPayment for PTA services:
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)
What is the cost sharing for Medicare B beneficiaries?
oMonthly premium:
oDeductible:
oCoinsurance:
oMonthly premium: $164.90
oDeductible: $226
oCoinsurance: 20%
Quality Payment Program:
*What is MIPS?
*What are Alternative Payment Models?
*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)
Define medical necessity and skilled care. Why is it important?
-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
What is the Advance Beneficiary Notice (ABN) form? When should it be issued?
-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
What is a Notice of Exclusion from Medicare Benefits (NEMB)?
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
Can a clinic bill for services provided to a Medicare Part B beneficiary that were provided by a student? What are the requirements?
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
Explain Medicare Part B rules/regulations for co-treatment.
-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
Discuss Medicare Part B rules/regulation for direct access to PT services in
*private practice:
*outpatient hospital settings:
*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
Discuss payment by private insurance for PT services provided via direct access.
-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
What are some of the different types of Cash Based Practices?
-all cash based (out-of-network providers)
-hybrid (cash + private insurances, cash + Medicare)
-mobile/concierge
List the different places a Cash Based Practice can reside:
anywhere!
-mobile
-in home
-within a gym or fitness center (rent space)
-within other healthcare facilities
-a stand alone clinic
How is payment received in a Cash Based Practice?
-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
What is a SuperBill?
-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
Can Medicare Beneficiaries pay cash for PT services covered by Medicare?
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
Describe the 3 relationships a cash PT clinic can have with Medicare:
oNo Relationship:
oParticipating Provider:
oNon-Participating Provider:
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)
What is a Limiting Charge?
a non participating provider can charge a Medicare beneficiary 15% above the Medicare payment fee
What is the Mandatory Claims Submission Rule?
if a pt is a Medicare beneficiary, you must bill Medicare. they cannot pay cash. Also applies to pts with Medicare Advantage Plans
How are School Based Services funded? Should parents pay for PT services in the educational setting?
-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
How are Early Intervention Services funded? What is the cost to parents?
-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
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:
effective, safe, efficient, patient-centered, equitable, and timely care
