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Health care delivery > Government and Entitlement Programs : Medicare > Flashcards

Government and Entitlement Programs : Medicare Flashcards

(58 cards)

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1
Q

How are payments under medicare justified?

A

payment prohibited for claims lacking information

Payment made for only claims medically necessary.

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2
Q

About 2/3 of medicare spending is ___

what about the other 1/3

A

traditional medicare

to private plans (C + D)

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3
Q

Medicare is required to pre-determine what

A

a base payment rate for service given.

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4
Q

How does medicare adjust payment for service?

A

based on location and complexity of patient.

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5
Q

List of medicare providers?

A 
Hospitals
Physicians
SNF
HHA
inpatient rehab
Hospice
Long-term care
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6
Q

Paid hospitals per beneficiary discharge

A

Acute care hospitals.

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7
Q

How are acute care hospitals paid

A

using inpatient prospective payment system..

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8
Q

Based rate for each discharge in Acute care hospital?

A

Diagnosis Related Groups

Higher payment for more intense level of care.

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9
Q

Who may receive added pay, in terms of acute care hospitals

A

teaching hospitals/ those with a high ant of low income beneficiaries .

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10
Q

Rates based on patient case mix which is relative resource intensity that would be associated with each patient’s clinical condition as identified through resident assessment process

A

Medicare IRF

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11
Q

What are cases grouped into in the Medicare IRF?

A

Rehabilitation impairment Categories

include adjustments.

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12
Q

CMS 60% rule?

A

facility must prove that at least 60% of admissions meet qualifying conditions

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13
Q

Why are IRFs paid at higher rate than rehab setting?

A

they provide rehab to pts who cannot be served in less intensive environments.

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14
Q

What are some IRF qualifying conditions?

A 
stroke
SCI
AMputaion/deformity
HipFx
brain/neuro
burn
arthritis
Jt. replacement
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15
Q

Freestanding or hospital-based facilities that provide postacute inpatient nursing and/or rehabilitation services.

A

SNF

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16
Q

Medicare pays SNFs one of ____ for each patient. what is based on?

A

66 pre-determined daily rates

based on level of nursing and therapy needs.

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17
Q

In SNFs there is a daily added payment from Medicare for care provided to pts. with

A

AIDS.

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18
Q

What does the Resident assessment process create and what does it determine?

A

Minimum Data set (MDS)

determines care plan.

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19
Q

Care in a SNF is covered with what is met.

A

1: pt. requires services
2: requires services on daily basis
3: services reasonable
4: services on inpatient basis.

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20
Q

What is the RUGS III Classification System?

A

Resident characteristic and health status.

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21
Q

Categories of RUG III

A
  • rehab + extensive service
  • impaired cognition
  • behavior probs
  • complex case
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22
Q

Rug classifications within 7 days

A 
720 mins: Ultrahigh
500 mins: Very high
325 mins: high
150 mins: Medium
45 mins: low
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23
Q

Classification for Medicare home health PART A

A
  • homebound
  • requires part time nursing/PT
  • care directed by physician
  • covers cost of first 100 Days.
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24
Q

What is OASIS used for in home health case ?

Study These Flashcards
A

to assign patient to Home health resource group

determine payment rate

25
for home health how does case rate change?
partial episode: pt reaches goal significant change in condition.
26
Medicare B at home used when
Medicare A 100 ddays runs out.
27
for hospice: what part of medicare is used?
A from approved program.
28
how is hospice payed?
Agency paid a daily rate for each day enrolled based on level of care regardless of whats done but
29
Levels of care in hospice?
Routine home care continuous home care Inpatient respite care General inpatient
30
Payment for outservice based on
Resource-based relative value update scale.
31
Non-physicians who bill independently typically receive a
15% reduction in payment.
32
Majority of OP services in what 3 settings
Private practice SNF Hospital OP
33
BasisforMedicareB(outpatient)payment including physical therapy
Resource Based Relative Value scale (RBRVS)
34
what is the concept behind RBRVS
price paid for a service should be based on cost of providing that service.
35
RBRVS based on what? what is that divided into?
Relative Value units (RVU) Work expense Practice expense professional liability insurance.
36
In order for a service to be covered under medicare what is necessary?
must have benefit category in law must be necessary and reasonable must not be excluded.
37
For medicare part B, what is necessary
- individual NEEDS services | - monitored by physician and while under care.
38
How is cared deemed reasonable and necessary?
- must be accepted as effect Tx. - can only be preformed by PT - amt/frequency must be acceptable.
39
Skilled service is when a professional needed to provide service is what goals?
improve limitations maintain Fx status Prevent deterioration of function.
40
All skilled services must be provided by
qualified PT or PTA
41
BasisforMedicareB(outpatient)payment including physical therapy
unskilled.
42
physician’s/NPP’sapprovalofthe plan of care. Requires a dated signature on the plan of care (or other document that indicates approval of POC)
certification
43
physician assistant, clinical nurse specialist, nurse practitioner who may certify if permitted by state and local laws
Nonphysician practitioner
44
MD, DO, DPM, (optometrist limited to low vision).
Physician
45
not considered physicians for therapy services and may not refer or establish therapy POC
Chiropractors and dentists
46
PT,OT,SLP,MD,NP, CNS or PA, licensed or certified by state to perform therapy services. May include PTA and COTA under supervision of qualified therapist as allowed by state law
Qualified Professional.
47
Orders are needed for?
- evidence of need for care | - certification and physician certification.
48
Plans of care need to be established before
treatment. eval and treatment can occur same day.
49
Beneficiary must have proper notice of
Non coverage.
50
non-covered services:
those not within scope: Statutorily medically unnecessary.
51
Services by PTA vs PT aides
PTA covered PT not covered.
52
Purpose of therapy cap?
to save resources needed to balance federal budget.
53
When did OP hospitals include cap?
2012. APTA trynna repeal.
54
What did the Medicare Access and CHIP reauthorization Act of 2015 do?
Repealed the flawed sustainable growth rate formula.
55
What are some big medicare reforms upcoming?
from fee-for-service-> payment on quality and outcomes Merit based incentive payment system.
56
Therapy cap for PT and OT?
$1,980 separate.
57
MACRA ? what is considered?
medical review process comparing providers new providers providers with claim denials.
58
What is the comprehensive care joint replacement model?
medicare alternative payment model for elective jt. replacement.

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