Skilled Nursing Reimbursement Basics Flashcards Preview

Health Policy > Skilled Nursing Reimbursement Basics > Flashcards

Flashcards in Skilled Nursing Reimbursement Basics Deck (22)
Loading flashcards...
1
Q

What is the MDS?

A

Minimum Data Set. Determines the approparite RUG level and amount of money for the client

2
Q

What did the 1997 Balanced Budget Act change?

A

Changed Reimbursement to a prospective payment system and mandated that the MDS would drive the payment.

CMS (Center for Medicare and Medicaid Services created RUGS(Resource Utilization groups) for patients using Part A services

3
Q

Who qualifies for Medicare?

A
  1. Must have paid into Medicare or be married to someone who paid into medicare for at least 10 years
  2. 65+ years
  3. Disabled for 2 years and receiving SSDI
  4. End stage renal disease
4
Q

How does one qualify for skilled care under medicare Part A

A
  1. 3 day qualifying hospital stay (3 midnights)
  2. 30 day window after release from hospital
  3. Needs skilled level of care
  4. Practical matter test
  5. Diagnoses
5
Q

______ days= one benefit period

A

100 days

6
Q

Medicare pays for 100% of _______ days of treatment/stay

A

20 days

7
Q

T/F For the last 80 days of a benefit period, the client/patient has to pay co-payment or use co insurance

A

True. The first 20 days are 100% covered by Medicare Part A, after they have a daily co-pay of 161.00

8
Q

T/F Services are provided 5-7 days/week

A

True

9
Q

T/F The initial evaluation is included as therapy minutes

A

False

10
Q

Explain the reimbursement basics for Part A in skilled nursing

A
  1. Paid per diem based on RUG level. (Determined by the MDS)
  2. Uses 7 day look pack period(Assessment Reference Periods) to capture therapy services provided
  3. Assessment Reference Date (ARD) is the last day of the assessment reference period and reimburses based off those 7 days
  4. 66 different categories for reimbursement
11
Q

What things do RUGS determine?

A

Resource Utilization Group

  1. Combination of minutes of all therapies, frequency of therapy and disciplines involved
  2. Each minute of therapy counts, not units
  3. Needs to be hands on therapy time
  4. Divide minutes by the number of people co-treating
12
Q

List all of the documents that need to be included in a patient file in order to be reimbursed

A
  1. Evaluation
  2. Justification of Daily Services
  3. Progress Report
  4. Supervisory visits (# of visits a COTA can do before the OT has to physically be there.. 10 visits or 30 calendar days)
  5. Re-evaluation
  6. Discharge Summary
13
Q

How are DME and AD paid for in skilled nursing? Which equipment is included?

A

Part of Medicare Part A
Part of consolidated billing, no separate charge
Basic mobility and safety devices included in per diem rate

14
Q

T/F If you want Part B insurance, you must buy into the system with monthly payments

A

True (121.80/month)

15
Q

T/F Part B covers patients residing in a long term care setting

A

True

16
Q

Part B is reimbursed by
A. Units of time
B. Minutes

A

A. Units of time

17
Q

How many treatments can a COTA do before an OT needs to be present under Part B?

A

10 Tx

18
Q

How does reimbursement work for DME and AD with medicare part B

A

80% reimbursed,,, patient responsible for last 20 %

19
Q

How long is a certification period, and how do you get it?

A

90 days, after initial eval is signed by the physician. Can get more time after a re-eval and another signature.

20
Q

T/F there is an annual limit to outpatient services. Medicare will cover 100% of this amount.

A

False. There is a annual limit, however medicare part B will only pay for 80% of visits. A secondary insurance will need to pay for the last 20%

21
Q

How does commercial insurance pay for skilled nursing care?

A

Variety of coverages depending on the plan
Need pre-approval for therapy visits
Case manager dictates discharge dates based off of progress
Reimbursement is done by contract levels or RUG levels
Require updates to case manager every 1-3 days
DME and AD may or may not be covered. Up to the discretion of case manager

22
Q

What is the 1987 Omnibus Reconciliation Act (OBRA) state/require?

A

Mandates a standardized resident assessment in long-term care/skilled nursing