Unit 2- WK5- Payment Across the Health Care Continuum Flashcards
How are visits to the emergency department billed to Medicare Part B ?
Fee for service, CPT codes, physician fee schedule
How are ICU, CCU, PCU and Acute Care financed ?
Inpatient Prospective payment system ( IPPS)
In acute care a patient’s primary diagnosis determines assignment to a ____________.
MS-DRG
Medicare pays for _______ days of hospital care per “spell of illness”, plus an additional lifetime reserve of ______ days.
90, 60
Define a single spell of illness
From hospital admittance to discharge from facility and gone 60 days without readmittance.
What are the 2023 Hosptial deductible, coinsurance for 61st-90th day, and daily coinsurance for lifetime reserve days, for Medicare Part A beneficiaries
1600
400
800
Explain the Hospital Value Based Purchasing Program
incentive payments for providing quality care, following best clinical practices, enhancing patient experience
Explain the hospital readmissions reduction program:
charges hospital fees for excessive readmission. 2% reduction in payout
Explain the Hospital Acquired Condition Reduction program
charges hospitals for injuries or complications occurring in the hospital 1%/
How can PTs have an impact on Acute Care Hospital Quality of Care ?
Reducing readmissions
discharge recs
enhancement of care transitions
minimize patient harm events
improve patient satisfaction; clear expectations
How is an LTACH paid and how are patient classified into payment groups ?
long term hospital prospective payment system; one time lump sum based on MS-LTC-DRGs
A Medicare beneficiary sspent 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 ?
80 days
How is an inpatient rehab facility paid and how are patients classified into payment groups ?
IRF prospective payment system
IRF-PAI to classify patients
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 ?
85 days
What happens on day 61-90 for Medicare beneficiaries staying in an inpatient rehab facility ?
They must pay a coinsurance
What is the Medicare 60% compliance rule for IRF?
60% of facilities population must meet one or more specific pathological conditions
What is the IRF-PAI used for?
payment determination and quality measure at discharge
What happens if an LTACH or IRF fails to submit their quality report annually ?
2% point reduction in annual payment.
What system is used to pay a SNF ?
SNF-PPS
What is the minimum data set used for in a SNF? (MDS)
What determines classification thus reimbursement. Only for Medicare Part A.
The payment classification system in SNFs is called:
patient driven payment model
How is Medicare’s payment to the facility adjusted starting on day 21 of a SNF stay ?
2% decrease each week after day 20
How many nights must a patient have had a hospital stay to qualify for admittance to a SNF
3 nights
Medicare Part A will cover up to _______ days per spell of illness, as long as a patient _________
100 days, 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
Define this mode of treatment: Individual
1 patient at a time
Define this mode of treatment: Concurrent
2 patients being seen by one therapist: doing different things
Define this mode of treatment: Group
2-6 patietns, performing same or similar task
Define this mode of treatment: Co-Treatment
2 clinicians with one patient at the same time. Performing different treatments.
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 ?
The student is an extension of the therapist
they must be individual or concurrent, since there is only “one” therapist
Differentiate Medicare Part A and B in terms of Home Health
A: patient from hospital or SNF for 3 days
must receive home health services within 14 days
cover first 100 days per spell of illness
Part B covers after 100 days
B: no hospital stay required
no deductible, co-insurance, or copayment
DME requires 20% coinsurance
unlimited coverage of home health visits if meets criteria
A home health plan of care is based on a 60 certification period. However, each episode of care last for _________. What is used to determine how much a home Health Agency is paid for each episode of care ?
30 days
The case mix adjustment flow chart which assigns a classification and rate.
Do medicare beneficiaries have cost sharing for home health care services ?
No, except for DME 20%
What is the max number of 30 day episodes of care in the home health setting ?
no limits
What services are covered in the 30 day episode of care rate in the home health setting ?
nursing, therapy, non routine medical supplies, home health care aide, medical social services
What is the OASIS and what is it used for ?
A patient specific , standardized assessment used to plan care, determine reimbursement and measure quality
done every 30 days to give new HHRG which gives a new rate
Who pays for DME in home health care ?
20% coinsurance
Who pays for palliative care ? Is maintenance therapy covered for patients receiving palliative care ?
home health medicare Part A, Yes
What is the difference between routine and continuous care under the Medicare Hospice Benefit Plan ?
Routine: beneficiary has chosen hospice at their place of residence
Continuous: care provided between 8-24 hours/day during periods of crisis: keep person comfortable
Where are Medicare Part B services provided ?
Outpatient PT clinics
Hospital Based Outpatient
SNF
Home Health
How are outpatient PT services billed under Medicare Part B? What system is used ?
Paid via retrospective payment system
billed using CPT codes and ICD-10 codes
uses physician fee schedule
What is the time period for certification of the plan of care by the physician or nonphysician practitioner for outpatient PT ? How often does the plan of care need to be recertified ?
30 days, 90 days
Discuss the following in Medicare Part B payment for therapy services: KX modifier
after a patient has spent $2150 on PT and SLP; the modifier must be added to the bill
continued therapy is medically necessary
Discuss the following in Medicare Part B payment for therapy services: Targeted Medical Review
- Above $3000
CMS review of insurance claim
Must submit documentation to medicare
Discuss the following in Medicare Part B payment for therapy services: Payment fot PTA services
85% of service cost
What is the cost sharing for Medicare B beneficiaries in outpatient PT?
Monthly premium: $164.90
Deductible: $226
Coinsurance: 20%
What is MIPS ?
Merit based incentive payment
prioritizes quality of care
must report if PT qualifies
What are Alternative payment models ?
a way to reward clinicians for quality care
incentives1
Define medical necessity and skilled care. Why is it important ?
Service provided for purpose of preventing, minimizing, or eliminating impairments, activity limitations, and or participation restrictions
medicare Part B pays for it
What is the ABN form ?
notifies beneficiary that medicare may not cover services and charges may come out of pocket
if providing services that PT knows medicare won’t cover
What is a NEMB ?
states that the patient will be financially liable for services.
Can a clinic bill for services provided to Medicare Part B beneficiary that were provided by a student ? What are the requirements ?
Yes, when the CI is responsible in the session
Explain Medicare Part B rules/regulations for co-treatment.
2 therapists cannot bill separately
must split treatment time
Discus Medicare Part B rules and regulations for direct access to PT services in private practice and outpatient hospital settings.
private: patient must have a physician, POC must be certified by physician within 30 days, POC good for 90 days, must re-certify POC if goal changes, 90 days after initial visit, POC has expired
outpatient hospital: responsible for patient’s care, licensed, within scope of practice, or authorized by hospital, doesn’t have to be certified by a physician
Discuss payment by private insurance for PT services provided via direct access.
Policy determined by insurer, may need referral, verify coverage
What are some different types of cash based practices ?
all cash based
hybrid
mobile/concierge
List the different places a Cash Based Practice can reside:
Mobile
In your home
within a gym or rented space
Within other healthcare facility
a stand alone clinic
How is payment received in a cash based practice ?
cash, check, credit, debit
set your own fees
usually purchasing sessions or programs
What is a superbill ?
A bill listing ICD-10 codes, CPT codes, and # of units forr code
bill includes amount charged for visit
all documentation
Can Medicare beneficiaries pay cash for PT services covered by Medicare ?
No, must charge medicare
Describe the relationships that a cash PT clinic can have with medicare
no relationship
Participating provider: enroll in medicare, agree to their payment schedules
Non-participating: medicare pays part, patient pays the rest
What is a limiting charge ?
25$/unit (4), medicare pays 95$ patient pays 14.25. Medicare can pay 95% of bill then PT can bill 15% more.
What is the mandatory claims submission rule ?
a beneficiary must be billed through medicare.
How are school based services funded ?
Medicaid, local resources ( set by state)
third party funding should not be used
How are early intervention services funded ?
state, medicaid, private insurances
normally free to parents unless there is an exception in that state.
How are early intervention services funded ?
state, medicaid, private insurances
normally free to parents unless there is an exception in that state.