Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

OTH Management > Reimbursement > Flashcards

Reimbursement Flashcards

1
Q

How do OTs get paid?

A

Reimbursement: monies from Patient Visits or Charges

Contracts to provide services elsewhere

Sales (equipment sales)

Tuition received for Continuing Education Offerings

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Why do we need to know about reimbursement

A

Customer Satisfaction

Prevent Claim Denials

Accurate documentation of services

Prevent Fraudulent Claims

Job Security

Security of Our Profession

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Established NPI
National Provider Identifier- 10-digit number

A

Identifies the practitioner who provided service
Get once start working
(connected to specific place of work)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Electronic Health Care transaction and code sets

A

standard coding for documenting billing and diagnostic information

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the most common insurance?

A

Medicare and medicaid, employee funded and worker’s comp

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Tricare is for

A

active duty military

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

IDEA

A

education mandate through education system

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Deductible:

A

monies client pays out of pocket prior to being eligible for insurance coverage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Co-payment: aka co-pay:

A

set amount client pays for each visit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Co-insurance:

A

percentage client pays for services (often 20%)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Medicare

A

Elderly or Disabled

Funding by federal government

Participants pay premium

PPS (prospective payment system) with retrospective review

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Medicaid

A

Indigent or Catastrophic

Funding Shared by state and federal
(state administers)

Low fee for service

Some providers refuse to accept or are not authorized to accept

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Who can get medicare A

A

Hospital insurance program
inpatient rehab
inpatient services
hospice
psychiatric hospital
skilled nursing facility inpatient
skilled home health

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What does Medicare Part B cover

A

Outpatient services
-Dr. and specialist
Doctor & specialist visits
Outpatient OT, PT, nutrition, psychology, etc
Outpatient testing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What does Medicare Part C cover

A

Managed Care Plan provided through private insurance (may charge additional premium)
Patient pays premium: covers A & B
may provide other benefits: dental, vision…

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Medicare part D can cover

A

Prescriptions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is the NY standard for medicaid

A

NY State eligibility (compared to Florida)
Individual: in NY eligible if income less than $18,755/year

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Note: Federal Poverty Guide

A

1 person = $13,590 4 person =$27,750

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Child Health Plus

A

NY Program to insure children
Aimed at those above Medicaid level
Individual making below $58,320 (maximum income level) can get insurance for their children at a reduced sliding scale cost

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the mandatory services covered by Medicaid

A

Mandatory services covered
i.e., Hospitalization & SNF including OT, lab, x-ray

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

How does Medicaid pay

A

Number of visits, time period or types of conditions eligible, where provided (only at hospital outpatient)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

PACE - Program for all-inclusive care for the elderly

A

For individuals who are eligible for both Medicare and Medicaid.

Program agrees to provide all health care services to that individual for an annual fee
From Doctors visits to hospitalizations to nursing home admissions to home health in exchange for a monthly rate from both Medicare and Medicaid.

PACE locally: Schenectady

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Private Health Insurance

A

Employer funded or ACA purchased from Marketplace

Under 65-years-old mainly

Every company is different, but often follow Medicare’s recommendations and standards

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What service of Medicare is this?

Substance abuse inpatient

A

Med A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
What service of Medicare is this? surgery for hip replacement?
Med A
26
What service of Medicare is this? hospice care at home
Med A
27
What service of Medicare is this? Skilled Nursing Home inpatient due to need for ventilator
Med A
28
What service of Medicare is this? psyciatric hospitalization due to suicide attempt
Med A
29
What service of Medicare is this? Substance abuse inpatient
Med A
30
What service of Medicare is this? Hospice care at home
Med A
31
What service of Medicare is this? outpatient hand
B
32
What service of Medicare is this? outpatient substance clinic
B
33
What service of Medicare is this? Dr. Office visit for upper resp infection
B
34
What service of Medicare is this? Copay made as an MVP patient for outpatient therapy for a medicare patient MVP
C
35
What service of Medicare is this? any services offered through CDPHP as a Medicare pt
C
36
What service of Medicare is this? prescription for lydex for use in outpatient therapt with ultrasound
D
37
Outpatient OT services get paid by
Often a set fee negotiated with billing department for insurance company to pay
38
What kind of copay does a pt pay for OT?
specialist
39
Federal Employees Health and Benefit Program (FEHBP)
Services provided to active and retired federal employees National model for health care reform Administered in 350 different plans Despite minimal coverage laws many have significant OT visit limits that are often combined with other therapies
40
Department of defense healthcare
TRICARE Programs For active duty military & family Services mostly provided at military health care facility and paid in full Veterans Program For honorably discharged military Services can be provided outside of a VA facility, but may incur greater cost to the individual
41
Individuals with Disability Education Act (1980 & 1997)
Requires funding of services from the state and local funds including school taxes to provide: free and appropriate education, which emphasizes special education and related services to meet individual needs
42
Worker's comp
Insurance for the worker injured ON the job Includes: Wage replacement benefits Medical treatment Vocational rehabilitation Financed by individual employers and state
43
Outpatient Worker's comp
Treatment must be focused on Restoring function (goal: RTW within 6 months) Focus on active, not passive type therapy Must re-evaluate 2-3 weeks after 1st visit and 3-4 weeks there after. Max 8 weeks without variance request.
44
Worker's comp MTG = Medical Treatment
Guidelines Established for shoulder, back, knee, and Carpal Tunnel Other areas require prior approval
45
No Fault
Medical coverage related to a Motor Vehicle Accident No copay, generous coverage
46
Outpatient OT and No Fault
Case manager may attend therapy session: checking in to assure services are reasonable and the patient is progressing Verify by calling to see that client is “No Fault” eligible
47
Uninsured
Majority are: Young, white men (with Hispanic population following), without a college diploma, who work full time in retail or wholesale trades for low wages
48
Percentage of working age adults uninsured 2009: 2014: 2022:
21% 13% 8%
49
Billing can be based on:
Based on a formula of minutes provided or severity of patient diagnosis/condition or Flat rate for all rehab services in a given day (OT, PT, SLP)
50
Common Procedural Terminology (CPT) Code
National based codes for treatments
51
What is required to bill
ICD-10
52
ICD-10 codes are
diagnosis codes
53
International Classification of Diseases Standard language created by
WHO
54
Used in billing to describe patient’s condition
ICD-10
55
Code used to describe condition
ICD-10
56
Code used to describe a procedure (often surgical)
G-Codes
57
Fee Schedule:
Our list of how much we hope to charge
58
Often a negotiated or established charge with each given reimbursement agent (Medicare, CDPHP, Medicaid all have set payment schedules)
established fee schedule for outpatient services
59
What do YOU think the OT manager has to consider when determining what to charge?
Time to complete Level of complexity Skill Required Amount of direct supervision of the patient Supply Expenses Reimbursement Potential Frequency of Services
60
RVU: Relative Value Unit
Coded charge Dollar amount also based on Relative Value Unit
61
HCPCS Codes
HCPCS = Healthcare Common Procedural Codes Established in 1978
62
in outpatient CPT codes are used for
direct billing
63
iin in patient we still bill out codes but usually insurance companies aren't going to see CPT codes meaning
used to demonstrate level of service provided
64
Outpatient: CPT codes
used for direct billing
65
CPT Code: HCPCS Level I
Widely recognized by insurances and Medicare & Medicaid as standard coding Time based codes: must pay attention to the minutes of therapy provided therapeutic exercise, self care training, neuromuscular re-education Service based codes: one unit no matter how much time it takes to complete OT evaluation, splint fabrication, hot pack/cold pack
66
DME: Hixpix: HCPCS Level II Durable Medical Equipment
Includes devices that are used at home for medical necessity Wheelchair, walker, hospital bed Does not cover basic expenses for adaptive equipment (not seen as medically necessary)
67
Purposes of Documentation
Chronological Record legal list of what happened Comply with Reimbursement Medicare likes the words: function and safety Communicate call in sick…can someone pick up where you left off? Clinical Reasoning show you are providing a skilled OT service…if it looks like PT or looks like nursing or looks like Rec Therapy…guess who will be doing your job in the future! Collect Data Are you providing some quantitative demonstration of progress as well as qualitative? Courtroom Defense 10 years from now can you or someone else tell what you did?
68
Point of Service Documentation
Document while you provide care
69
Reduce de-personalizing patient care during point of service documentation by:
Explaining why you are writing or typing so patient feels connected to what is happening Pause writing when you are asking questions Make eye contact while asking questions and for at least the beginning of the answer
70

OTH Management (21 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions