Types of Payments & Regulatory Compliance

What does Medicare Part A cover?

It covers part of expenses for inpatient stays and is known as 'hospital insurance.'

What settings are paid by the Prospective Payment System (PPS) in Medicare Part A?

Hospitals, inpatient rehabilitation facilities, psychiatric hospitals, and skilled nursing facilities.

What does DRG stand for in the context of Medicare Part A?

Diagnosis-Related Group.

How many days is skilled nursing facilities covered by Medicare part A?

up to 100 days, with services being at least five days a week

What does PDPM stand for?

Patient-Driven Payment Model.

What does PDPM base its payments on?

based off of what clients needs are

(therefore, looking at needs, and seeing what client (tools) requires for reimbursement).

What are all the settings covered by Medicare part A?

home health, hospice, hospital, inpatient rehab facility, psychiatric hospital, skilled nursing facility

What do occupational therapists (OTs) focus on in hospice care?

Maintaining function or reducing symptoms to enhance quality of life.

What does Medicare part B cover in cost?

Cover some costs for outpatient care such as:

- physician visits and OT

- some home health services

- some supplies and durable medical equipment

How much percent does Medicare B cover in outpatient?

- covers 80% of the cost for "medically necessary" outpatient (PT, OT, SLP)

- patient will pay for remaining deductible not covered, and then pays 20% of remaining cost

deductible

Amount you pay out-of-pocket for healthcare services before insurance starts to pay.

How often do you need to pay for premium to cover for Medicare part B?

monthly premium

What durable medical equipment is covered in medicare part B?

(reusable medical equipment)

-walkers, wheelchairs, and hospital beds

What type of equipment in medicare part B is mostly NOT covered?

- reachers

- bathtub seat

- dressing sticks

- grabbers

What is medicare Part C?

(AKA medicare advantage plan)

A bundle plan that comes from private companies that work with Medicare

What is medicare Part D?

Covers for prescription drugs

(D for drugs)

Who does federal employees health benefits program cover for?

Retired and active federal workers

Who are federal workers?

They are individuals who work for the government

Who does TRICARE provide care for?

TRICARE provides care for:

- Active duty service members

-retirees

- their families

- survivors

- certain former spouses

Who does Medicaid cover for?

Covers for

-Those with disabilities

-Those who have income less than a certain amount

What does a 21-year-old have access to when they have medicaid?

Screening

diagnosis

treatment

What does CHIP stand for?

children's health insurance program?

Who does CHIP cover for?

- healthcare for children for low income families, but they have too high income for Medicaid

What does IDEA stand for?

Individuals with disability education improvement Act

What is IDEA?

helps provide those with disabilities with free appropriate public education

Worker's compensation program

They provide money and medical benefits for those who have work related injury or a disease related to the job

Who do OTs work with in a worker's compensation program?

OTs work with those who are

-covered by worker's compensation insurance (and)

-clients injured on the job.

What are OTs focus in a worker's compensation program?

helping clients to recover so they can go back to work.

What is a diagnosis code?

A diagnosis code is a medical label for client's condition.

What is a procedure code?

Procedure code is specific service provided by OT.

Medicare Recovery Audit Program

It identifies improper billing and ensures billing is accurate and goes along with Medicare rules.

What is an audit according to the Medicare audit program?

it make sure everything is aligned with the established guidelines

When would a practitioner try to appeal the process to challenge a decision?

If OT services are denied, practitioners can appeal the process to challenge the decision.

Medicare fraud

intentionally lying for financial gain.

Abuse(according to medicare)

practices that cause unnecessary costs to Medicare.

False claims act(according to medicare)

It protects the government from being overcharged.

Anti-kickback statute

Makes it illegal for healthcare providers to exchange anything of value to influence patient referrals for services paid by a federal government.

According to HIPAA what is a national provider identifier?

professional ID card for billing

What is the joint commission?

an organization that focuses on improving healthcare for the public

What does CARF international focus on?

It focuses on improving the quality of services in order to meet. Patient needs to get the best outcome.

What is the American disabilities act?

It does not allow discrimination based on disability in employment

What is copyright issues?

A protection that prevents others from taking someone else's published or unpublished work unless they have the originator's permission

What is malpractice?

It happens when OT does not provide standard of care which then cause injury

What are 5 ways to prevent malpractice?

1. ensure adequate supervision

2. Staff education for safety

3. Have other employers peer review others

4. Document OT sessions in accurate and timely manner.

5. Respectful and clear communication with clients.