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Flashcards in Government Payor Reforms Deck (18)
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1

TEFRA

Tax Equity & Fiscal Responsibility Act of 1982

2

What did TEFRA establish?

Established first prospective payment system (PPS) for acute hospital care
-created DRGs

3

What also did TEFRA introduce?

utilization review bodies for Medicare called Peer Review Organizations (PROs)

4

What was the goal of DRGs?

Reduce utilization of inpatient acute care

5

BBA

Balanced Budget Act of 1997

6

Purpose of BBA

to fix hospital discharging to post acute setting

7

Payment for SNF

per diem

8

Payment for Home Health

case rate

9

Payment for outpatient hospitals (APCs)

case rate

10

Payment for Outpatient rehab & physicians (MPFS)

fee schedule

11

Payment for IRF

case rate

12

Payment for LTACH

case rate

13

Retrospective

payor knows how much to pay after receiving the bill from the provider

14

Prospective

payor knows what will be paid before receiving the bill from the provider for a given condition or length of stay (benefit for the insurer)

15

How is home health paid?

The first episode begins a 60 day period.
For that first episode the HH Agency (HHA) is paid 60% up front by Medicare than 40% after discharge
If the patient is discharged and restarted before that original 60 days is over, then it is a second episode and the HHA receives 50% up front and 50% at discharge.

16

IRF qualifications:

60% of ALL patients admitted (whether Medicare or not) must fall within thirteen (13) diagnostic categories.
Patients must receive at least three (3) hours of PT+OT+SLP per day (can be any combination of the three disciplines, such as only 1, 2 of them, or all 3 of them)

17

Medicare Modernization Act of 2003

Established Medicare Part D prescription drug benefit plan
Was considered the largest overhaul of Medicare in its 38 year history

18

CPT

Current Procedure Terminology