Reimbursment

Question 1

HIPPA

Answer 1

(2008) Health insurance Portability & Accountability Act

Question 2

(HIPPA) Establishes NPI

Answer 2

National Provider Identifier : 10 digit # used for billing

Question 3

(HIPPA) Electronic Health Care transaction and code sets

Answer 3

Standard coding for documenting billing & diagnostic information

Question 4

(HIPPA) Health information Privacy

Answer 4

Strengthened confidentiality information to minimum needed for intended purpose

Question 5

(HIPPA) Security

Answer 5

Set standards for managing both electronic & paper information
Made standard billing codes required by insurance companies

Question 6

ACA Obama Care

Answer 6

Patient Protection & Affordable Care Act

Question 7

ACA Obama Care Overview

Answer 7

Expand health care coverage to 32 million low & middle income and those employed by small business at affordable cost
Original plan did NOT mention OT as a covered service

Question 8

ACA Sample of Proposed Changes

Answer 8

Taxation of “cadillac” plans: those with NO co=pays or out of pocket expenses which have no personal incentive to limit costs.
Rewards to MDs for managing chronic illness
Phased out of Medicare Advantage Programs

Question 9

Health Care Reform : Sample Changes (1)

Answer 9

More physician assistants and nurse practitioners providing primary care services
More control by individual states
-more pts. eligible for Medicaid
-Medical marketplace (2017) where affordable insurance can be purchased by individuals or small business owner (managed by the state)

Question 10

Health Care Reform : Sample Changes (2)

Answer 10

Tax incentives to small business for those that provide employees access to insurance
Young adults up to 26 y.o. can stay on parents insurance
Adds free preventative services

Question 11

Health Care Reform : Sample Changes (3)

Answer 11

No longer can bar from getting insurance or cancel insurance d/t catastrophic or chronic illness
Most Americans are required to get coverage or pay a penalty

Question 12

Before ACA ? (2010)

Answer 12

67% Private Health Insurance 
13% Medicaid 
12% Medicare 
4% Military 
15% No health insurance

Question 13

Public Funded Programs : Medicare

Answer 13

Elderly or disabled
Funding by federal government
Participants pay a premium
PPS (prospective payment system) with retrospective review

Question 14

Public Funded Programs : Medicaid

Answer 14

Indigent or Catastrophic 
Funding Shared by state and federal 
Low fee for service 
Some providers refuse to accept or are not authorized to accept 
Hospitals have to accept medicaid pts.

Question 15

Medicare Part A : Hospital Insurance Program

Answer 15

Hospital in pt. services 
In pt. rehab 
Psych hospital stays 
Hospice care 
SNF Inpatient stays 
Skilled Home Health

Question 16

Medicare Part A : Hospital Inpatient PPS

Answer 16

Prospective payment system
Rate per day is driven by level of service a particular hospital provides
Per episode rate covers all services including OT
Based on DRG (i.e. THR)

Question 17

Medicare Part A : Hospital Inpatient PPS Facilitated

Answer 17

Utilization Review (LOS & Services)
Clinical Pathways
Care Managers
Push toward alternative level of care (d/c to SNF, Rehab, Home health)

Question 18

Utilization Review

Answer 18

Primary tool of Managed Care Insurance but now used in most insurances
System to evaluate the necessity, appropriateness, and efficiency of use of services (most hospitals have a UR department)
Used to control over-utilization, reduce cost, and manage care.

Question 19

Utilization Reviews : Typical Activities

Answer 19

Pre-admission certification
Mandatory 2nd opinion before surgery
Case manages to monitor care of a particular pt.

Question 20

Clinical Pathways

Answer 20

Care plans developed to manage care of smiliar cases in a standard way
Example: Admission for hip replacement
-clinical pathway will trigger automatic orders: lab work, nsg care, prn pain meds
-Rehab ordered in a standard way
-i.e. Day 1: Pt. bedside for transfers and ambulation

Question 21

Medicare Part A : Psych Hospitilization

Answer 21

DRG Exempt: paid on a per diem rate that covers all needed services based on statistics of each hospital costs

Question 22

Medicare Part A : Hospice

Answer 22

Physician must certify the client is terminally ill
OT may only provide services to control symptoms or maintain ADL & basic functional skills (activity adaptation & adaptive equipment)

Question 23

Medicare Part A : Inpatient Acute/Subacute Overview

Answer 23

TO be called a rehab facility they need to have a specific mix of conditions admitted
Generally payment is for 100 days or less unless extenuating circumstances

Question 24

Medicare Part A : Acute Rehab

Answer 24

Active therapy + 3 hour rule for eligibility.

• Pt.’s admitted need active therapy from a minimum of two disciplines (OT, PT, SLP, Prosthetics) one must either be OT or PT
• To be eligible for rehab pt. must be able to tolerate 3hrs of combined therapy 5 days per week

Question 25

Medicare Part A : SNF

Answer 25

Eligible first 100 days only id pt. needs SKILLED nsg (i.e. decubitis care) PT, OT, or SLP Must recieve services at lease 5 days/week Must have been hospitalized for a minimum of 3 days prior to admission to qualifiy

Question 26

Medicare Part A : Subacute Reab

Answer 26

Generally located in the SNF Less strict than acute: three tiers of service with pay based on # of hours of therapy combined PT/OT/SLP 1-2 hrs of therapy per day

Question 27

Medicare Part A : Payment for SNF & Subacute

Answer 27

OT Part of daily rate: -covers all needed services -subacute pt.s are paid based on the level of therapy receiving based on min per day and min per week Documentation : Resident Assessment Instrument (RAI) Includes: MDS- Minimum data set (tells you where pt. level of A is) RUGS- Resource Utilization group (# of min and what resources were used)

Question 28

Resident Assessment Instrument : MDS

Answer 28

Minimum Data Set | -screening of A core set of clinical and functional status elements

Question 29

Resident Assessment Instrument : RUGS

Answer 29

Resource Utilization Groups based on ACTUAL performance -OT often complete ADL portion -Determine pt. complexity based on 53 levels & this determines billing rate -includes monitor of mins of therapy/week

Question 30

Medicare Part A : Home Health Agency (HHA)

Answer 30

Eligibility based on need for skilled nursing PT or SLP -OT covered only after qualifies for above skilled service -once receiving OT can continue to do so even f other skilled services are no longer needed. Therapist often do more than therapy -monitoring BP, routine tx's

Question 31

Medicare Part A : HHA Continued

Answer 31

Payment is provided based on a single rate for 60 days based on prediction of care needs upon completion of screening tool Payment covers all services -OASIS : Outcome & Assessment Information Set (documentation form) -completed initally by PT, nsg, or SLP -OT will provide input and may complete OASIS once active on case

Question 32

Medicare Part B : Supplementary Medical Insurance Program

Answer 32

Out pt. services (i.e. doctor visits, OT, PT) OT treatment cost is based on current procedural terminology (CPT code) -Docementation must reflect services is part of identified code chosen -Must show improved function or safety Annual deductible 80/20 -cap is about $1920 per year for OT/PT/SLP Retrospective review d/t red flags

Question 33

Durable Medical Equipment (DME)

Answer 33

Includes devices that are used at home for medical necessity -w/c, walker, hospital bed -does not cover basic expenses for adaptive equipment (not seen as medically necessary) Facility is requires to have a DME # in order to charge for DME equipment -orthotic devices are not seen as DME except in private practice settings

Question 34

Medicare Part C

Answer 34

Medicare advantage Alternative choice that covers both A & B Managed care plan provided through private insurance Results in lower cost to federal govt. & can provide some other benefits (dental, vision)

Question 35

Medicare Part D

Answer 35

Prescription Plan

Question 36

Medicare & OT

Answer 36

Requires current MD prescription & plan of care approved by physician Requires a SKILL performed by an OT (not something an aid could do) & be performed by a qualified OT or OTA Reasonable and necessary for the tx. of the identified illness or injury -focused on improved safety or function

Question 37

Medicare changes & AOTA

Answer 37

Law requires that there is an opportunity for public comment prior to implementation AOTA monitors and provides assistance in interpreting potential changes to its membership AOTA lobbies for your benefit (be an AOTA member)

Question 38

Medicaid (1)

Answer 38

Regulated by each state (matching federal funds) - NY state eligibility (compared to Tx) - individual: income less than $9200/year -TX $2247 - Family of 4: income less than $17,000'/year - TX $4630 Child Health Plus Ny program to insure children Aimed at those above medicaid level Individual making up to $43,000 can get insurance for their children at a reduced sliding scale cost

Question 39

Medicaid (2)

Answer 39

Mandatory services -i.e. hospitalization & SNF including OT, lab, xray Optional Services -Outpt. OT & Orthotics -FFS (fee for service) with max total -62% of states cover OT -Many limit the amount of OT (# of visits, time period or types)

Question 40

Program for All-Inclusive Care for the Elderly (PACE)

Answer 40

For individuals who are eligible for both Medicare &Medicaid These programs agree to provide all health care services to that individual for an annual fee from doctors visits o hospitalizations to nursing home admissions to home health in exchange for a monthly rate from both Medicare and Medicaid PACE locally: Schenectady

Question 41

Other Public Funded Programs

Answer 41

``` Federal Employees Health & Benefit Program (FEHP) TRICARE Veterans program IDEA Workers Comp Indian Health Services Grant funded programs ```

Question 42

Federal Employees Health & Benefit Program (FEHBP)

Answer 42

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 visits that are often combined w/ other therapist Strickly limited on # of therapy visits

Question 43

Department of Defense Health Care Programs : TRICARE

Answer 43

For active duty military | Services mostly provided at military health care facility and paid in full

Question 44

Department of Defense Health Care Programs: Veterans Program

Answer 44

For honorably discharged military | Services can be provided outside of a VA facility but may incur greater cost to the individual

Question 45

IDEA

Answer 45

Individuals w/ disavbilities education act (1990 &1997) A free and appropriate education which emphasizes special education and related services to meet individual needs Requires completion of Individual Education Plan (IEP) or Individual Family Service Plan (IFSP) 1998: Medicare Catastrophic Coverage Act -allows school systems to bill Medicaid for services that are Medically Necessary

Question 46

Pediatric : Early Intervention

Answer 46

``` 0-2 years State Health Dept. County coordinates Fee schedule by county Documentation must support self-help, adaptive behaviors. ```

Question 47

Pediatric : Preschool

Answer 47

``` 3-5 years State education department School district coordinates Fee schedule by county Documentation must have educational focus ```

Question 48

School Age Pediatrics

Answer 48

5-21 years State ed department CSE coordinates (committee on special education) Must have > 1 year delay Documentation must be educationally based May include medicaid funding

Question 49

Workers Compensation

Answer 49

Wage replacement benefits, medical tx, & vocational rehab. Financed by individual employer and state MTG = Medical tx. guidelines -established for sh. back & knee -other areas require prior approval -MTG for Carpal Tunnel in review process OTA's & PTA's cant treat pts.

Question 50

Workers Compensation (Continued)

Answer 50

Treatment must be focused on -restoring function (goal: RTW w/in 6 mos.) -focus on active not passive therapy Must re-evaluate 2-3 weeks after 1st visit and 3-4 weeks there after. Max 8 weeks w/o variance request.

Question 51

Private Health Insurance: Indemnity Plan

Answer 51

Traditional FFS (fee for service) 80/20 Few rules Expensive

Question 52

Private Health Insurance: HMO

Answer 52

Health Maintenance Organization No claims for, wellness approach, cost containment Gaitkeepers: Primary Care Physicians -capitation: MD pair per member, prospective ammount -early plans had incentives for staying below costs

Question 53

Private Health Insurance : POS

Answer 53

Point of Service: type of HMO that allows more member decisions of when to use out of network or to access specialist w/o first seeing primary care physician

Question 54

Private Health Insurance: HDHP

Answer 54

High Deductible Health Plan | Members pay a high deductible but have 100% coverage for preventative; incentive to contain cost in pushed to the memebr

Question 55

Private Health Insurance & OT

Answer 55

Often set fee that has been negotiated w/ billing department Watch for limits on # of visits Co-pays increasing Fee per day regardless of service : one lump fee if receive OT & PT on the same day

Question 56

No Fault

Answer 56

Medical coverage related to a motor vehicle accident - no copay generous coverage - usually has a case manager checking in to assure services are reasonable and pt. is progressing - case manager may come to therapy visit - do need to check if client is no fault eligible

Question 57

Uninsured

Answer 57

% of working age adults uninsured -2009 : 21% -2014 : 13% Majority are: young white men (with hispanics following) w/o a college diploma, who work full time in retail or wholesale trades for low wages