What is the MDS?
Minimum Data Set. Determines the approparite RUG level and amount of money for the client
What did the 1997 Balanced Budget Act change?
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
Who qualifies for Medicare?
- Must have paid into Medicare or be married to someone who paid into medicare for at least 10 years
- 65+ years
- Disabled for 2 years and receiving SSDI
- End stage renal disease
How does one qualify for skilled care under medicare Part A
- 3 day qualifying hospital stay (3 midnights)
- 30 day window after release from hospital
- Needs skilled level of care
- Practical matter test
- Diagnoses
______ days= one benefit period
100 days
Medicare pays for 100% of _______ days of treatment/stay
20 days
T/F For the last 80 days of a benefit period, the client/patient has to pay co-payment or use co insurance
True. The first 20 days are 100% covered by Medicare Part A, after they have a daily co-pay of 161.00
T/F Services are provided 5-7 days/week
True
T/F The initial evaluation is included as therapy minutes
False
Explain the reimbursement basics for Part A in skilled nursing
- Paid per diem based on RUG level. (Determined by the MDS)
- Uses 7 day look pack period(Assessment Reference Periods) to capture therapy services provided
- Assessment Reference Date (ARD) is the last day of the assessment reference period and reimburses based off those 7 days
- 66 different categories for reimbursement
What things do RUGS determine?
Resource Utilization Group
- Combination of minutes of all therapies, frequency of therapy and disciplines involved
- Each minute of therapy counts, not units
- Needs to be hands on therapy time
- Divide minutes by the number of people co-treating
List all of the documents that need to be included in a patient file in order to be reimbursed
- Evaluation
- Justification of Daily Services
- Progress Report
- Supervisory visits (# of visits a COTA can do before the OT has to physically be there.. 10 visits or 30 calendar days)
- Re-evaluation
- Discharge Summary
How are DME and AD paid for in skilled nursing? Which equipment is included?
Part of Medicare Part A
Part of consolidated billing, no separate charge
Basic mobility and safety devices included in per diem rate
T/F If you want Part B insurance, you must buy into the system with monthly payments
True (121.80/month)
T/F Part B covers patients residing in a long term care setting
True
Part B is reimbursed by
A. Units of time
B. Minutes
A. Units of time
How many treatments can a COTA do before an OT needs to be present under Part B?
10 Tx
How does reimbursement work for DME and AD with medicare part B
80% reimbursed,,, patient responsible for last 20 %
How long is a certification period, and how do you get it?
90 days, after initial eval is signed by the physician. Can get more time after a re-eval and another signature.
T/F there is an annual limit to outpatient services. Medicare will cover 100% of this amount.
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%
How does commercial insurance pay for skilled nursing care?
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
What is the 1987 Omnibus Reconciliation Act (OBRA) state/require?
Mandates a standardized resident assessment in long-term care/skilled nursing