Admin and education

Medicare

• for elderly/disabled

• federal health insurance program for adults 65 years and older or for younger individuals with qualifying disabilities or end stage renal disease (ESRD)

• 4 parts: A through D

medicare Part a

• hospital insurance

• covers:

  • inpatient hospital care

  • skilled nursing facility

  • care following qualifying hospital stay

  • hospice

  • some home health services

medicare Part b

• covers outpatient medical services

• physician vists

• outpatient OT/ST/PT

• durable medical equipment

• preventive services

medicare Part C

• private insurance plans that combine parts a and b

• often include additional benefits

medicare Part d

prescription drug coverage

skilled nursing facility under medicare part generally require

• qualifying hospital stay

• need for skilled nursing or therapy services

• medicare eligibility

medicaid

• joint federal and state health insurance program that provides healthcare coverage for individuals with low income

• eligibility and covered services vary state by state

managed care plans

• HMO

• PPO

• POS

HMO (health maintenance organization)

• lower cost

• must generally stay within provider network

• primary care physician coordinates care

PPO (preferred provider organization)

• greater provider choice

• can use out of network providers (usually at higher cost)

• referrals typically not required

POS (point of service)

• combines HMO and PPO features

• primary care physician coordinates care but some out of network services are covered

ACA (affordable care act)

• prevents denial of insurance due to pre-existing conditions

• expanded access to healthcare and rehabilitation services

• increased insurance coverage for many americans

insurance denials and appeals

if equipment or therapy services are denied

1. determine why the claim was denied

2. review documentation

3. submit an internal appeal to insurance company

4. request a peer to peer review if appropriate

5. if needed pursue an external review by an independent reviewer

strong appeals include

1. clear documentation

2. functional justification

3. medical necessity

4. supporting physician documentation

fraud

• the intentional submission of false information for reimbursement

• ex:

  • billing for services not provided

  • upcoding (billing for a more expensive service)

  • falsifying documentation

• fraud is illegal and may result in fines, loss of licensure, or criminal penalties

documentation and ethics

• every client encounter should be documented

• documentation:

  • supports medical necessity

  • communicates with the healthcare team

  • tracks progress toward goals

  • supports reimbursement

  • serves as a legal record

common types of documentation

• evaluation: initial assessment and plan of care

• daily/encounter note: summarize progress toward goals

• progress note: summarizes progress toward goals

• discharge summary: documents outcomes and discharge recommendations

good documentation should be

• accurate

• timely

• objective

• complete

leadership styles

• autocratic

• democratic

• laissez-faire

autocratic leadership

• leader makes decisions independently

• useful in emergencies

democratic leadership

• team members participate in decision making

• promotes collaboration

laissez-faire leadership

• employees work independently with minimal direction

• appropriate for experienced staff

effective leaders

• communicate clearly

• listen actively

• provide constructive feedback

• resolve conflicts professionally

• coach and mentor employees

• promote teamwork and quality improvement

supervision

• ensures safe, ethical, and competent occupational therapy practice

• 4 levels

  • close (frequent communication for new or less experienced practitioners)

  • routine (weekly supervision as competence develops)

  • general (monthly supervision or as needed)

  • minimal (independent practice with contact as needed)

communication during supervision can include

• face to face meetings

• telephone calls

• video conferencing

• other scheduled communication

managing employees

when performance concerns arise

1. identify the problem

2. develop a performance improvement/action plan

3. provide coaching and feedback

4. monitor progress before considering disciplinary action

strategic planning

• mission: why organization exists

• vision: what the organization hope to become

• strategic plan: goals and priorities for the next 3 to 5 years

• budget: financial plan forecasting revenues and expenses

accreditation and quality improvement

• joint commission

• CARF

• continuous quality improvement

joint commission

• accredits healthcare organizations by evaluating:

  • patient safety

  • quality of care

  • compliance with standards

• healthcare professionals should understand and follow joint commission standards to promote safe, high quality care

CARF (commission of accreditation of rehabilitation facilities)

• an independent, voluntary accrediting organization

• recognizes rehabilitation programs meeting high standards of quality and services

continuous quality improvement (CQI)

• continuous, data driven process used to improve patient care and organizational performance

• projects should align with

  • organizational mission and vision regulatory requirements

  • department priorities

  • patient outcomes

school based ot and transition planning

• occupational therapists help students prepare for adult life by developing skills related to

  • employment

  • postsecondary education

  • independent living

  • community participation

examples of school and transition planning ot

• public transportation

• money management

• shopping

• time management

• self-advocacy

• vocational readiness

transition services for school and transition planning ot

• the IEP

• student’s transition plan

advocacy

occupational therapists advocate because legislation and policy directly affect

• access to occupational therapy services

• insurance reimbursement

• client rights

• the future of the profession

types of advocacy

• grassroots advocacy: individuals contact legislators or policymakers to support issues affecting clients or the profession

• legislative advocacy: professional organizations (such as AOTA) work to influence laws and public policies

advocacy may include

• containing legislators

• educating policymakers

• participating in AOTA advocacy efforts

• promoting access to occupational therapy services