Lec 5: Gov't Entitlement Programs: Medicare Flashcards
(150 cards)
1
Q
___% of everything the US spends goes to Medicare
A
15%
2
Q
CMS stands for
A
Center for Medicare and Medicaid Services
3
Q
CMS was formerly known as ____?
A
HCFA, government agency under dept. of health and human services
4
Q
What is the federal agency that managed Medicare?
A
CMS
5
Q
Interpret the laws through…
A
Regulations
6
Q
Medicare promulgates what?
A
Regulations
7
Q
Medicare’s program management is by who?
A
Contractors (MACs)
8
Q
4 Medicare “Rules”
A
Law
Regulations
Coverage determinations: National and Local
MedPAC
9
Q
Who makes the laws?
A
Congress
10
Q
National coverage determinations are by:
A
CMS
11
Q
Local coverage determinations are by:
A
MAC or contractor
12
Q
MedPAC is the _______ to congress and they have no _________
A
Advisory group
NO direct power
13
Q
What does MedPAC do?
A
Will look at access, quality and payment to care and will make recommendations back
14
Q
PDF handouts: Medicare (1965) is for people over the age of _____.
A
65
15
Q
PDF handouts: If you are under the age of 65, you may be covered if you are… (3 things)
A
Permanently disabled
ESRD
ALS
16
Q
PDF handouts: Medicare A is what?
A
Hospital coverage
17
Q
PDF handouts: Medicare Part B is what?
A
OP/Ambulatory
18
Q
PDF handouts: What is the difference between Medicare Part A and B?
A
A is the one where people pay into it over working life
B is paid for by general revenue (tax payers) and beneficiaries
19
Q
PDF handouts: What is Medicare C?
A
Newer type of Medicare (Medicare Advantage) –> Medicare HMO
20
Q
PDF handouts: What are the advantages to Medicare C?
A
Plans are less expensive
21
Q
PDF handouts: What are the disadvantages to Medicare C?
A
More restrictive
22
Q
PDF handouts: Medicare D is for?
A
Drugs
23
Q
PDF handouts: Which medicare is optional?
A
B, you can choose to enroll there
(Can also choose Medicare Advantage C, instead of A and B
24
Q
PDF handouts: What is the health status of Medicare population?
A
Older and sicker
Almost half have 4+ chronic conditions
25
PDF handouts: Most medicare beneficiaries live where?
AT HOME! Only 5% live in LTC
26
PDF handouts: Medicare has ______ cost-sharing requirements
HIGH
27
PDF handouts: Is there an annual OOP spending limit in Medicare?
NO
28
PDF handouts: Medicare A typically has a _______ for hospitalization after a certain about of time
Co-insurance
29
PDF handouts: Medicare B has a _______ _______ that people have to pay. They will also have a _____ and 20% __________
Monthly premium
Deductible
Co-insurance
30
PDF handouts: Medicare C and D require what?
Premiums
31
PDF handouts: When you have Medicare, you have high _____ spending
Out of pocket
| Because you are paying premium up front and then OOP for most of services
32
PDF handouts: A lot of Medicare Spending/Financing goes to _______
Hospitals
33
PDF handouts: There is NOT a linear relationship between beneficiaries and how much you spend on them, T/F?
True
34
Public document for providers
CMS.gov
35
Public document for beneficiaries
Medicare.gov
36
Payment is prohibited by law for claims that what?
Lack necessary info to process the claim
37
Payment is made only for those services that are considered medically ______ and _______
reasonable and necessary
38
About ____ of Medicare spending is traditional Medicare. About ____ to private plans (Medicare C and D)
2/3 traditional
| 1/3 private
39
If you do not have to send the documentation in, how do they get it?
THEY DO AUDITS, you must present your documentation on demand if you get audited
40
Medicare is required to _____________ a base payment rate for a given unit of service
Pre-determine
41
Medicare adjusts its payment for each unit of service provided based on variables such as what?
Provider's geographic location
| Complexity of patient receiving the service
42
Examples of Medicare Providers?
```
Hospitals
Physicians
SNFs
Home Health Agencies
IRF
Hospice Agencies
LTC Hospitals
OP Dialysis Facilities
Ambulatory Surgical Centers
Inpatient Psychiatric Facilities
DME suppliers
Ambulance providers
Labs
```
43
Acute Care Hospitals: Paid hospitals per beneficiary discharge using the ______
Inpatient Prospective Payment System
44
Acute Care Hospitals: Base rate for each ________: __________; further adjusted for patient ________
Discharge
Diagnosis Related Groups
Severity
45
Acute Care Hospitals: Higher payment for DRGs that are likely to incur more ______ levels of care and/or _____ lengths of stay
Intense
| Longer
46
Acute Care Hospitals: Also account for a portion of hospitals' _______ and _________
capital
| operating expenses
47
Acute Care Hospitals: Some ________ hospitals or those with higher shares of ________ beneficiaries receive added payments
Teaching
| Low-income
48
Acute Care Hospitals: You get paid by _______
Diagnosis
49
Medicare IRF: Rates based on _____ _______ _____ which is the relative resource intensity that would be associated with each patient's clinical condition as identified through resident assessment process (_______)
Patient case mix
| IRF-PAI
50
Medicare IRF: Cases grouped into ____ ______ ______
Rehab Impairment Categories
51
Medicare IRF: Also includes facility level adjustments, T/F?
True
52
The CMS 60% Rule that's that IRFs are paid at _______ rate than other rehab setting
HIGHER
53
CMS 60% Rule: Provide intensive rehab services to patients who cannot be service in what kind of environments?
Less intensive
54
CMS 60% rule: What do patients need to have for admission?
Qualifying conditions
55
According to the CMS 60% rule, facility must prove that at least ____ of admissions meet qualifying conditions
60%
56
Examples of CMS IRF Qualifying Conditions
```
Stroke
SCI
Congenital deformity
Amputation
Major multiple trauma
Fracture of femur
Brain injury
Neuro disorders
Burns
Arthritis related medical conditions -3 (complex)
Knee or hip joint replacement (complex)
```
57
Skilled Nursing Facilities: Freestanding or hospital based facilities that provide what kind of services?
Postacute inpatient nursing
And/or
Rehab services
58
Skilled Nursing Facilities: Medicare pays SNFs one of ____ pre-determined daily rates (categorized as ______) for each patient, based on patients' expected level of nursing and therapy needs
66
| Resource Utilization Groups (RUGs)
59
Skilled Nursing Facilities: SNF payments incorporate ______ and _____ costs for providing care to Medicare patients
Operating
| Capital
60
Skilled Nursing Facilities: there is an added family payment from medicare for care provided to beneficiaries with _____
AIDS
61
Skilled Nursing Facilities: ______ necessity for skilled nursing and/or rehab services
Physician
62
Skilled Nursing Facilities: Resident assessment process, created __________, which determine the care plan
Minimum data set (MDS)
63
Skilled Nursing Facilities: The RUGS III Classification system looks at what?
Resident characteristics and health status
64
Skilled Nursing Facilities: What is payment based on?
RUGS relative resource, cost from high to low
65
Skilled Nursing Facilities: How is payment measure?
In minutes of care
66
CARE IN A SNF IS COVERED IF ALL OF THE FOLLOWING 4 FACTORS ARE MET. What are they?
1. Pt requires skilled nursing services or skilled rehab services (performed under supervision of professional or technical personnel) and order by a physician
2. Pt requires these skilled services on a DAILY BASIS
3. The daily skilled services can be provided only on an INPATIENT bases in a SNF
4. Services must be REASONABLE AND NECESSARY
67
Examples of minimum data set categories
```
Cognition
Communication
Vision
Mood/Behavior
Physical function
Continence
Psychological
Medical Dx
Health Condition (last 7 days)
Pain
Oral/Nutrition
Skin condition
Activity pursuit patterns
Medication
Specific treatment procedures
Discharge potential
```
68
RUG III Categories
```
Rehab plus extensive services
Rehab
Extensive services
Special care
Clinically complex
Impaired cog
Behavior problems
Reduced physical function
```
69
```
RUG classifications (rehab): Within last 7 days, at least 5 days:
ULTRA HIGH:
```
720 minutes of more, at least 2 disciplines
70
```
RUG classifications (rehab): Within last 7 days, at least 5 days:
VERY HIGH:
```
500 minutes, at least one discipline
71
```
RUG classifications (rehab): Within last 7 days, at least 5 days:
HIGH:
```
325 minutes, at least one discipline
72
```
RUG classifications (rehab): Within last 7 days, at least 5 days:
Medium:
```
150 or more minutes, any combination of 3 disciplines
73
```
RUG classifications (rehab): Within last 7 days, at least 5 days:
Low:
```
45 minutes 3 days any combo 3 disciplines AND 2 or more rehab nursing services
74
Medicare Home Health Services (PART A): Must be ________
Home bound
75
Medicare Home Health Services (PART A) Patient requires ______ initial skilled nursing, PT and/or ST< or continuing OT
PART TIME
76
Medicare Home Health Services (PART A): Care must be directed by a ______
Physician
77
Medicare Home Health Services (PART A): Must be provided by ___________ HHA
Medicare Certified
78
Medicare Home Health Services (PART A): Covers cost of what?
First 100 days after prior 3-day hospital stay
79
Home Health Care Rate: What tool is used to assign patient to home health resource group (HHRG)?
OASIS
80
Home Health Care Rate: OASIS will determine what?
Payment rate
81
Home Health Care Rate: _____ day episode as basic unit of payment
60
82
Home Health Care Rate: What are two instances of case rate changes?
1) Partial episode payment - beneficiary reaches goals
| 2) Significant change in condition adjustment - patient change from initial POC
83
Medicare B at home: Coverage when?
100 day Part A benefit exhausted OR
| 3-day hospital stay requirement not met
84
Medicare Hospice Benefit: Part __
A
85
Medicare Hospice Benefit: The individual is certified as having _______ with a prognosis of _________ if the illness runs its normal course
Terminal illness
| 6 months or less
86
Medicare Hospice Benefit: The individual receives care from what?
Medicare approved hospice program
87
Medicare Hospice Benefit: Individual must sign a statement indicating that he or she elects the hospice benefit and _______ all other rights to Medicare payments for services for the terminal illness and related conditions
WAIVES
88
Hospice Services Covered includes:
Physician services
Nursing care
Medical equipment/supplies
Drugs for symptom control and pain relief
Hospice aid and homemaker services
PT
OT
SLP
Social Worker
Dietary counseling
Spiritual counseling
Grief and loss counseling for the individual and his/her family
Short term inpatient care for pain control and Sx management and for respite care
Any other services as IDed by the hospice interdisciplinary group
89
Hospice Payment Rates: Agencies paid a _______ rate for each day a beneficiary is enrolled in hospice benefit
Daily
90
Hospice Payment Rates: T/F: Payments are made regardless of the amount of services furnished on a given day and are intended to cover costs that the hospice incurs in furnishing services IDed in POC
True
91
Hospice Payment Rates: Payments are based on the level of care required to meet beneficiary and family needs: What are 4 types of home care?
Routine home care
Continuous home care
Inpatient respite care
General inpatient care
92
Outpatient providers: Medicare and other services provided by a ______ or _______
Hospital
| Other qualified provider
93
Outpatient providers: Increased utilization after__________ and fewer restrictions on care
Hospital DRGs
94
Outpatient providers: Based on a ___________ for over 7000 services
Medicare Fee Schedule (MPFS)
95
Outpatient providers: Payment rates based on _______, since 1992
Resource Based Relative Value Update Scale (RBRVS)
96
Outpatient providers: Bonuses are given to physicians in designated ________
Shortage areas
97
Outpatient providers: Non physicians who bill independently typically receive a ____% reduction in payment
15%
98
Utilization of OP Therapy Services: PT = __% of OP rehab benefit under Medicare
88%
99
Utilization of OP Therapy Services: Majority in what 3 settings?
Private Practice
SNF
Hospital OP
100
Resource Based Relative Value Scale (RBRVS): Basis for Medicare _____ payment including PT
Part B (outpatient)
101
Resource Based Relative Value Scale (RBRVS): Concept: the price paid for a service should be based on what?
The cost of providing that service
102
Resource Based Relative Value Scale (RBRVS): Services classified and reported to CMS using what system?
Healthcare Common Procedure Coding System (LEVEL 1) via CPT
103
Resource Based Relative Value Scale (RBRVS): Payment rates based on relative weights called _______ divided into three categories or relative costliness of inputs used to provide services
Relative Value units (RVUs)
104
Resource Based Relative Value Scale (RBRVS): What are the 3 categories?
Work expense/value
Practice expense
Professional Liability Insurance (PLI) - malpractice expenses
105
Medical necessity under Medicare: In order for a service to be covered under Medicare, it must have 3 things:
Must have a benefit category in the law
Must not be excluded
Must be reasonable and necessary
106
Medicare Conditions of Payment (Part B): Services required because individual ______ therapy services
NEEDS
107
Medicare Conditions of Payment (Part B): Plan is establish by who? And is periodically review by who?
Physician/NPP
Physician/NPP
108
Medicare Conditions of Payment (Part B): Services provided while individual is what?
Under the care of a physician
109
Medicare Conditions of Payment (Part B): Furnished on ____ Basis
OP
110
Medical Necessity: Medicare benefit for therapy requires that the patient be under the care of a _______ for some diagnosis
Physician
111
Medical Necessity is determined by who?
Evaluating PT
112
Medical Necessity: Must be clear evidence of medical necessity documented in _________
PT DOCUMENTATION
113
Reasonable and Necessary: EACH OF THE FOLLOWING CONDITIONS MUST BE MET (4)
1) Services considered under accepted standards of medical practice to be a SPECIFIC AND EFFECTIVE Tx for pt's condition
2) Services are COMPLEX, or condition of patient requires, that services can ONLY be performed by a therapist or under supervision or therapist
3) PT diagnosis is NOT sole factor in determining skill - key determinants are need for therapist to treat illness, injury or disease process and whether services needed could by provided by other nonskilled personnel
4) Amt, freq and duration of therapy services must be reasonable according to accepted standard of practice
114
Skilled services: When the knowledge, abilities and clinical judgment of a therapist are necessary to safely and effectively furnish a therapy service for one of the following goals:
- Improvement of impairment or functional limitation
- Maintenance of functional status
- Prevention or slowing further deterioration in function
115
Skilled services must be provided by ________ or ________
```
Qualified professional (therapist)
Or
Qualified personnel (PTA)
```
116
Skilled services: once patient is judged safe for independent performance of an activity, skill of a therapist is ________ and services are __________
Not required
| No longer reasonable or necessary
117
Services provided by those who do not meet CMS qualification standards are not __________
Considered skilled
118
Services that are ________ or reinforce previously learned skills, or maintain function after a maintenance program is developed are considered _________
Repetitive
| UNSKILLED
119
What happened in Jimmy vs. Sibelius?
Class action law suit for Medicare beneficiaries that were denied services based on an arbitrary policy that denied coverage of PT and nursing services because there was no material improvement in patient's condition
There should be no improvement standard
Even when no improvement is possible, skilled maintenance therapy to prevent or slow deterioration is important!
There is a clear distinction now between restorative or rehabilitative therapy and maintenance thereapy
120
In restorative/rehabilitative care, what is the primary goal?
To reverse loss in function, and therefore assessing the potential for improvement is appropriate
121
In maintenance therapy, what is coverage based on
Improvement is not expected and should not determine coverage of care.
Coverage is based on an individualized assessment of the pt's condition and the NEED FOR SKILLED CARE to carry out safe and effective maintenance program
122
Certification:
Physician's/NPP's approval of the POC
Requires a dated signature on the POC
123
Non Physician Practioner (NPP):
PA, CNS, NP who may certify if permitted by state and local laws
124
Physician:
MD, DO, DPM
Chiros and dentists not considered physicians for therapy services and may not refer or establish POC
125
Qualified professional:
PT, OT, SLP, MD, NP, CNS, 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
126
An order/referral for therapy service provides _______ of both the need for care and that the patient is under the care of a physician
Evidence
127
Certification requirements for order/referrals are met when the _____ certifies the POC
Physician
128
Payment is dependent on the _________ of the POC rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan
CERTIFICATION
129
Plans of care must be established ________ treatment begins
Before
130
POC may be established by _______ or _______
MD/NPP
Or
Therapist provider
131
Evaluation and treatment may occur and are billable on ________
Same day
132
Payment for services provided before plan is established may be ______
Denied
133
Medicare (billing beneficiary directly): Beneficiary must have proper notice of ________
Non coverage (ABN)
134
Medicare (billing beneficiary directly): What are non covered services?
Statutorily non covered (not within scope of Medicare)
| Not covered as determined to be medically unnecessary
135
Medicare and PTAs: The services are billed by who?
The supervising PT
136
Medicare and PTAs: PTAs may not do what?
They cannot provide eval services
Make clinical judgments or decisions
Or take responsibility for the service
137
Medicare and PTAs: General supervision is required for all PTAs in all settings except ______ (which requires direct supervision)
PRIVATE PRACTICE
138
"Incident To" Services: Statute requires that payment be made for a therapy service billed by a physician/NPP only if the service meets the standards and conditions -- other than licensing -- that would apply to a therapist, T/F??
True
139
Therapy Cap: In 1997, Congress passed the _____________ that created an annual financial limit on PT and SLP, and a separate cap on OT, for all OP settings
Balanced Budget Act
140
Therapy Cap: Balanced Budget Act sole purpose was what?
To save resources needed to balance the federal budget
141
Therapy Cap: Exceptions process:
| Automatic exceptions for conditions IDed by CMS -- refers to ___________
Processing of claims
142
Therapy Cap Exceptions process: Uses of a _____ modifier
KX
143
Examples of conditions likely to qualify for PT
```
Joint replacement
Amputation
OA
Osteoporosis
Fracture
SCI
Head injury
Gait abnormality
```
144
What does MACRA stand for?
Medicare Access and CHIP Reauth Act
145
MACRA repealed what?
The flawed sustainable growth rate (SRG) formula
146
MACRA further extended the ___________ exceptions process to 12/31/17
Medicare therapy cap
147
MACRA began policy changes toward other significant Medicare reforms: Framework to move Medicare from a largely ________ program to a program that bases payment on _____ and _______
Fee for service
Quality
Improved outcomes
148
With MACRA, CMS will determine which therapy services to renew by considering (3)
1) reviewing providers with patterns of aberrant billing practices
2) providers with high claims denial % or who are less competent with applicable Medicare program requirements
3) newly enrolled providers
149
Comprehensive Care Joint Replacement Model:
Medicare alternate payment model for elective HIP and KNEE jt replacement patients
150
Comprehensive Care Joint Replacement Model: Payment is linked to _____ measurement and improved _________
Quality
| Outcomes of care
