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Final Exam Flashcards

(105 cards)

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1
Q

Elements of the triple aim?

A

improved health, cost containment, improved healthcare

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2
Q

CMMI is given wide authority to do what two things?

A

lower spending without reducing quality of care

2-improve the quality of care without increasing spending

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3
Q

What is an ACO?

A

a group of providers who agree to collaborate on both cost and quality, in exchange for shared financial incentives

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4
Q

bundled payment?

A

set amount is paid in exchange for cost associated w/ a major surgical procedure

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5
Q

3 ways insurers offset the risk of over or under treatment by providers?

A
  1. non-financial incentives
  2. mandates
  3. financial incentives
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6
Q

what is the risk with a per diem payment model?

A

patient under treatment; risk is on the provider

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7
Q

definition of value (HC)

A

health outcomes achieved per dollar spent

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8
Q

what is the ultimate outcome if the goal of “value” is achieved in healthcare?

A

patient outcomes and satisfaction

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9
Q

what payment model is the healthcare system IDEALLY trending towards?

A

multi-provider bundled episode of care payment

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10
Q

what is an example of “risk on the provider”

A

full capitation- would encourage patient under-treatment

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11
Q

what is an example of risk on the insurer?

A

fee for service- can lead to patient over treatment

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12
Q

3 new models through CMMI

A

ACO
bundled payment
medical home

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13
Q

what is a medical home?

A

team approach to care- rely heavily on PCP/team
coordination of health/wellness- esp medicare
fee for service PLUS monthly care management fees for activities related to patient care and coordination

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14
Q

ACO?

A

hospitals/doctors/providers group together to share collective accountability for quality/cost of care delivered to patients in their ACO
payments to ACOs incorporate financial incentives (shared savings or penalties) based on performance metrics

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15
Q

purpose of bundled payments

A

overall budget for services provided to patient receiving course of treatment for given clinical condition over a defined period of time

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16
Q

why is total joint replacement being used for bundled payments?

A

high cost, high utilization

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17
Q

general model of bundled payment for CCJR?

A

hospital where surgery takes place is financially accountable for quality and costs from date of surgery through 90 days. mandated in specific geographic areas-not voluntary
surgical procedure, inpatient stay, readmission, post acute care included
Med A or Med B costs
waves 3 night hospital stay requirement

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18
Q

how is the payment going to work for CCJR

A

for first year, retrospective payment where only CMS takes risk. After first year, both take risk as there is a target price determined. Anything over target price, hospital must pay back to CMS

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19
Q

what must a hospital due to qualify for CCJR reconciliation payment?

A

meet/exceed 3 quality measures (30 day readmit rate, complication rate in 90 days, hospital consumer assessment o healthcare providers and systems.

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20
Q

what is no longer required w/ CCJR?

A

3 night hospital stay if SNF has at least 3 out of 5 star rating
homebound requirement for home health
tele health restrictions (more liberally allowed)

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21
Q

what are 3 things that act to offset risk of over/under treatment

A

mandates, non-financial incentives, financial incentives

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22
Q

what mandates control over/under treatment?

A

requiring providers to do certain things or prohibit from doing things in order to receive payment. Then review level of compliance w/ those requirements

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23
Q

non financial incentives to provide proper treatment?

A

publicly reporting on providers’ performance

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24
Q

financial incentives for proper treatment?

A

provding payment rewards or penalties to providers based on performance

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25
what system is being developed by APTA to possibly take place of FFS?
PT payment and classification system (PTPCS)
26
what model does the PTPCS represent?
somewhere along the lines of per day or episode of care payment
27
3 new evaluation codes?
low moderate or high complexity. there would be a total of 9 codes w/ 1 reevaluation code and 5 examination/intervention codes
28
what is the point of APTA's new initiative- integrity in practice?
aimed to address fraud, abuse, waste
29
definition fraud?
intentional deception or intentional misrepresentation that a provider makes to gain benefit for which not entitled
30
abuse definition
payment for items or services when there is no legal entitlement to that payment and the provider has NOT knowingly and or intentionally misrepresented facts to obtain payment
31
waste
over utilization of services or other practices that directly or indirectly result in unnecessary costs to the health care system. Not criminally negligent actions, but by payment errors or misuse of resources.
32
why are there fraud/abuse issues w/ federal payers
retrospective payment system: pay and case | VERY complicated
33
describe the false claims act
imposes liability on person who submits a claim to CMS that they know is false. Protects fed gov from vein overcharged or sold substandard goods. Knowingly billing for services that were not provided
34
anti-kickback statute
criminal offense to knowingly and willfully offer, pay, solicit or receive bribes or kickbacks to induce or reward referrals in order to induce business reimbursable by fed health care program: cash payment, trips/fancy dinners
35
what is a safe harbor from the anti-kickback
not subject to anti-kickback statute because they are unlikely to result in fraud/abuse
36
describe physician self-referral law
physician referring a patient to a facility in which he or she has financial interest (ownership, investment, family members ownership). COI
37
3 critical questions to determine whether stark statute applies to particular arrangement
1. does arrangement involve referral of medicare or medicaid patient by physician or immediate family member of physician 2. is the referral for a designated health service (inuding PT) 3. is there a financial relationship of any kind between the referring physician or a family
38
what is the exclusion statute?
exclusion of providers convicted of medicare fraud, patient abuse/neglect, controlled substance distribution, default on health education loan/scholarship obligation- excluded from participation in medicare.
39
What are the 2 things that initial consent to treat applies to?
1. treatment: day to day documentations/communication | 2. health operations: Q/A, outcomes tracking
40
does medicare require physician order for PT services?
No, however a patient must be "under the care of a physician" indicated by the physician certification of the plan of care w/in 30 days of PT visit
41
what are the 3 things that POC for medicare must include?
1. diagnoses, 2. long term treatment goals, and 3. type, amount and duration of therapy services
42
when is recertification of the plan of care necessary?
if changes in patient's condition requires revision of long-term goals or within 90 calendar days from the date of the initial treatment
43
who can certify a plan of care according to medicare?
physicians and NP/PA's. Optometrists may certify only low vision services, podiatrists w/ scope of professional services.
44
podiatrist
3 years, MCAT, no bachelors required. DPM
45
physician assistant
has license but practices under a physician. typically 2-3 years
46
Advanced practice nurse/NP
must have written relationship w/ physician, but can have an independent practice in CO.
47
optometrist
NOT an MD
48
definition of medicare fraud
intentionally deceiving or misrepresenting the truth, knowing that it could result in some unauthorized benefit to himself/herself, or some other individual
49
examples of waste in medicare system
1. practices that are not consistent w/ goals of providing patients w /services that are medically necessary, meet professionally recognized standards, fairly priced 2. practices that result in unnecessary costs to the medicare program
50
which statute prohibits physician from making a referral for certain health services to an entity the physician has an ownership/investment interest or compensation agreement?
physician self-referral stark statute
51
which statute was violated in the power wheelchair scam discussed in class?
false claims act
52
what do the initials OD refer to?
optometrist
53
are psychiatrist and osteopath considered a medical physician?
yes. not podiatrist, psychologist, optometrist or chiropractor
54
which providers may sign off on PT POC?
osteopath, nurse practioner, PA, MD
55
What is DORA? role w/ PT?
governmental state agency- mission is to protect the public. Is an independent non-profit organization. also puts together NPTE
56
What are the 3 types of law?
1. criminal: usually involves jail, fine, probation 2. civil: usually results in monetary- involve private dispute 3. administrative law: enforcement of practice acts
57
sunrise
when profession applies for licensure- takes about one year.
58
what is the difference between licensure and certification
certification is a voluntary process by a private organization in order to provide public information on those individuals who have successfully completed the certification process
59
sunset
review of licensure occurs about every 10 years to determine: continued regulation necessary? operate in public interest? protect the public?
60
when is the next PT sunset?
2018
61
jurisdiction
legal authority to judge/act in a particular case. Ex: once licensed PT in CO, board has jurisdiction over PT forever
62
one of the times where PT board has jurisdiction over non-PT's
term protection- chiropractors and physicians can use physical therapy term
63
what happens with all cases brought to board other than those dismissed or dismissed w/ confidential letter of confer?
reported to national practitioner database. Information is permanently and publicly associated with your license
64
what is a letter of admonition?
letter admonishes the licensee for their conduct and warns them that repetition could lead to further disciplinary matters. This is a public censure
65
what happens during probation/practice limitation?
time period where practice is closely monitored during a specific period of time. possibly include courses or outside note reviews
66
2 categories of practicing below standard of care
1. financial | 2. physical/sexual
67
patient abandonment
frustrated w/ boss- walk out w/ full caseload of patients scheduled
68
reciprocity
process to get licensed in another state
69
what is the composition of PT board?
7 members- 5 PT's and 2 public members
70
document that gives more detail about enforcement and guidelines for the licensee to clarify statute
rules and regulations
71
definition general supervision
PT no required to be on site, but must be available at least by telecommunications
72
direct supervision
PT is physical present on premises and in same building (must be present w/ aides)
73
direction immediate supervision
PT is physically present or immediately available to support the individual being supervised- meant for students
74
how many people can PT supervise?
up to 4 individuals at one time. does not include students
75
Professions requiring general supervision by PT
PTA, CNA in some circumstances
76
professions requiring direct supervision by PT?
massage therapists when providing massage as part of PT POC, aide
77
requiring immediate supervision?
student PT or student PTA
78
are athletic trainers regulated?
not anymore, as the statue was "subsetted" las year
79
medicare part b requirements?
only support for a PT is a PT. no aides (CNAS can be included in home health)
80
Community Health Accreditation Program Inc. (CHAP)
independent, non-profit accrediting body- deeming authority by CMS
81
who is responsible for accreditation of medical rehabilitation programs?
CARF
82
definition disability
physical or mental impairment that substantially limits one or more major life activities of the individual, or record of such impairment, or being regarded as having such impairment, or known association or relationship w. person w/ disability
83
what is not covered under ADA?
minor, non-chronic condition of short duration such as sprain broken limb or the flue
84
covered entity definition
an employer, employment agency, labor organization, joint labor action committee and state/local governments
85
definition reasonable accommodation
modifications at the job workplace to enable a person w/ a disability to easily perform a specific job
86
definition undue bruden
action necessary to provide a reasonable accommodation that would cause the employer or owner significant difficulty or expense
87
definition of essential functions
reflects the primary reason a job exists and are performed by all workers who hold the job. If only some workers do that function in the job, then it is not essential
88
who is a qualified individual w/ a disability?
meets skill, experience, education or other requirement of position and can perform the essential functions of position (with or without reasonable accommodation)
89
who does title 1 apply to?
private employers, state and local governments, employment agencies, labor unions all employers w/ 15 or more employees
90
what does title I protect?
protects against employment discrimination- this includes w/ recruitment, advertising, job application, hiring/firing, advancement, compensation, training
91
does the ADA require employers to develop written job descriptions?
no, however a written job description that is prepared before advertising or interviewing applicants for a job will be considered as evidence along w/ other factors
92
does an employer have to give preference to a qualified applicant with a disability over other applicants
no- an employer is free to select the most qualified applicant available and to make decisions based on reasons unrelated to disability.
93
when can tests for illegal drugs be performed?
can be done pre- or post-offer
94
when is an employer required to make a reasonable accommodation?
only when applicant or employee's disability is known. generally triggered by a request form an individual w/ a disability. Accommodations made on an individual basis.
95
what does Title II protect?
pohibits discrimination against qualified individuals w/ disabilities in all programs, activities and services of public entities
96
title III
public accommodations necessary for new construction of commercial facilities
97
what 3 basic things must organizations do to comply w/ title III
1. physical access: parking, etc. 2. communication access- services available in alternative format 3. reasonable modification to policies: ex diabetes injection in stadium that prohibits sharp objects
98
describe fair labor standards act
time keeping and overtime compensation requirements, break/meal periods, minimum wage
99
what categories are exempt from the fair labor standards act?
executive, administrative, professional (attorneys, MD, etc.), creative professional
100
reasons qualifying for Family medical leave act?
birth/care newborn child, foster/adoption, care for immediate family member w/ serious health condition, employee unable to work due to serious health condition, qualifying military family leave
101
who is considered family w/ FMLA?
employees parent, child, spouse,
102
when are employees eligible for FMLA?
worked for employer at least 12 months, 1250 hrs, and work at location where company employs 50 or more employees within 75 miles
103
unemployment insurance definition
provides workers whose jobs have been terminated through no fault of their own, monetary payment sfor a given period of time or until they find a new job
104
what does unemployment insurance encourage?
sound employment decisions and progressive discipline. progressive discipline NOT required in state of CO
105
at will employment
employer may terminate its employees at will for any or no reason employer. no progressive discipline required. employee can also leave at any desired time

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