PT Roles Quiz 2

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-getting paid for what we do -paid after services rendered

Stakeholders impacting reimbursement

-practitioners/employers -3rd party payers -federal law -state law -other funders

3rd party payers

-health plans -insurance companies -medicare/medicaid

state law

State of Illinois Early Intervention Program

other funders

Division of Services for Specialized Care for children

Where does physical therapist income come from?

-pay yourself/receive income from another person/organization -paid: hourly, salary, per service -revenue needs to be generated to pay clinicians

a provider receives payment based on

-bundle of services including physical therapy -specific physical therapy services -a block payment or grant

Insurance benefits are usually limited by

-number of visits per year/per episode/ per condition -maximum dollar amount per year -insurers may exclude specific techniques or conditions from coverage

Medicare coverage administered by

The Centers for Medicare and Medicaid

Medicare coverage

-amercians 65+ who have worked and paid into system -younger individuals with disabilities, end-stage renal disease and amyotrophic lateral sclerosis

what are the four parts of medicare?

Part A, B, C, D

Part A

inpatient hospital and skilled nursing care, home health care, hospice care

Part B

supplementary medical insurance, doctor's services, rehab therapy services, other outpatient care, supplies not covered by part A

Part C

-Medicare Advantage -provided by private companies that have approval -offer all in one hospital and medical insurance (prescription, dental, vision)

Part D

-prescription drug coverage -premiums vary and weighted by income

Skilled Nursing Facility

-Covered by medicare part A -Qualifying hospital stay -Cost -Medicare Part B may be provided based on nature of medical need and if outpatient

qualifying hospital stay

prior 3 day hospitalization (inpatient)

cost for SNF

-Days 1 to 20 = 0 -Days 21 to 100 = 194.80 coinsurance per day -Days 101 and beyond= all costs -prospective payment system

Prospective Payment System (PPS)

paid a predetermined rate for each day of care based on patient needs

Acute Care Hospitals

-Medicare Part A -inpatient care -payment based on predetermined per discharge rates -cost

inpatient care

diagnosis and treatment of acute conditions, manifestations of chronic conditions

Payment based on predetermined per-discharge rates

primarily related to condition and treatment

cost for acute care

-$1,364 deductible for each benefit period -Days 1-60: $0 coinsurance -Days 61-90: $341 coinsurance per day of each benefit period -Days 91 and beyond: $662 coinsurance per each “lifetime reserve day”

Outpatient Services

-Part B -Medically necessary diagnostic and treatment services -Emergency or observation services -Lab tests -Preventive and screening services -Cost

emergency or observation services

may include overnight stay

Cost of outpatient services

-20% of the Medicare-approved amount -Medicare deductible ~ $185 or greater (depending on income)

Outpatient PT

-Part B -covers 80% -Beneficiary covers 20% after deductible met -Medicare covers $2040 for PT and SLP before provider indicates care medically necessary

Medicaid Coverage

-public health insurance program for low income americans -PT, optional program, can be covered at variety of facilities -PT not optional

when is PT not optional under medicaid

-inpatient hospital service -medically necessary under the Early, Periodic, Screening, Diagnostic and treatment program in schools

Federal and State Level PT reimbursement

-department of Defense (TRICARE) -department of veteran affairs -individuals with Disabilities education act (IDEA)

Modes of healthcare financing in US

-out of pocket -individual private insurance -employment based group insurance -government social insurance

What are the types of insurance?

-Preferred provider organization -Health Maintenance Organization -High Deductible Health Plan -Point of Service

Preferred provider organization

-PPO -see any health provider in network without referral (PT vary), in-network lower than out of network

Health Maintenance Organization

-HMO -choose primary care physician who directs all services to in network members and specialists

High Deductible Health Plan

-HDHP -higher initial deductible cost but lower yearly or monthly premiums

Point of Service

-POS -combine HMO and PPO -greater than HMO -use out of network services


-amount of money insured would need to pay before benefits from health insurance policy can be used -yearly amount


percentage amount that insured's responsibility -80/20 common split


fixed amount insured is required to pay at time of service

lifetime maximum

amount of money the health insurance policy will pay for entire life

Why do we need insurance?

important determinant to access health care


-no usual source of care -less likely to see healthcare provider in last six months -unmet healthcare needs -worse outcomes

financial burden

-medical bills biggest cause of US bankruptcies

What are the three levels of evaluation codes?

-low complexity -moderate complexity -high complexity

low complexity

-no personal factors/comorbidities -examination of body systems: 1- 2 elements -stable and uncomplicated

moderate complexity

-1 to 2 personal factors -examination of body system: 3 or more -evolving

high complexity

-3 or more personal factors -examination of body system: 4 or more -unstable and unpredictable

Diagnosis codes: pathology

-ICD - 10 - CM -Owned by World Health Organization

Procedure codes - current procedural technology American medical

-association owns the copyright (AMA) -uniform language: increase accuracy and efficiency -required for private practice, outpatient hospital, and medicare part B SNF -evaluation codes = procedure codes -interventions codes --> gait training, manual therapy, therapeutic exercise