6601 Leadership, Development, and Advocacy Midterm Review

Ready, Set, Treat main points

• Kristen and Susie’s experience developing a private practice

• Phase 1: Get Ready

  • brand practice, choose space

  • legal and liability needs

  • communication and financial technology

• Phase 2: Get Set

  • billing methods

  • register with CAQH —> credential with insurance

  • HIPAA compliant paperwork

• Phase 3: Treat

  • market

  • sweet spot

  • get paid

Main points for Jeanni’s Videos

• Independent contractor model for Early Intervention services in IL and TN

• S-corp → could hire employees down the line

• Bills private insurance, Medicaid, and some private pay

  • EI under part C of IDEA → pays minimum allowed amount (EI will cover the difference that insurance doesn’t cover)

• Advocacy: update language in TN Care policies, clarifications to MCOs, use therapy first langauge!!! —> implications for reimbursements

  • e.g. don’t bill S-code, bill OT codes for hippotherappy (not a separate service but used as therapeutic tool for part of comprehensive plan)

emerging treatment settings Q&A article main points

• OTs apply training and perspective to have positive impact on population’s health and well-being

  • refugee population

  • ER & first responders

  • incarcerated persons

  • postpartum

  • dental health

  • substance abuse

  • adaptive sports

ADA video main points

• 504 rehabilitation act had no regulations to implement it

• ADA was necessary b/c there needs to be a baseline for accommodation → reasonable accommodation

• Framework for how to deal with disability issues

  • 2 main ones were employment and transportation

one page business plan

• parts include

  • revenue goals

  • revenue insights

  • revenue risks

  • weekly schedule

  • client attraction activities

Social Security Amendments of 1965

• keywords: MEDICARE, MEDICAID, DME

• protect vulnerable populations

• established national public health program (MEDICARE & MEDICAID)

• Defined DME

Omnibus Reconciliation Act of 1987

• think: BUS for old people at nursing homes

• keywords: LTC/nursing home, care plans, restraint, optimal function/participation

• created national minimum standards of care and bill of rights for people in LTC

• required individual care plans (ADL, training staff, protect residents)

• protection from unnecessary & inappropriate physical and chemical restraints

Section 504 of Rehabilitation Act of 1973

• think: 504 plan for special ed in school (schools receive fed aid)

• keywords: program with federal aid, = education, special education

• no person, due to disability, excluded/denied benefits of program with federal aid

• schools ensure equal education for students with qualifying dx through special ed.

Americans with Disabilities Act of 1990

• think: end discrimination against adults w/disabilities

• keywords: title, housing-related, public places

• 5 titles (every student takes public transportation)

  • employment

  • state and local government

    • II: protections for housing-related programs, prohibits discrimination based on disability in publicly funded programs

  • transportation

  • public accommodation

    • III: prohibits discrimination based on disabilities of goods, services, facilities, privileges, accommodations of public places

  • telecommunications

individuals with disabilities education improvement act of 2004

• think/keywords: FAPE, EI, LRE

• Part B: students 3-21 have access to FAPE for further education, employment, and independent living

• Part C: children 0-3 access EI through provisions for states

• specifies children be removed from regular ed environment ONLY if disability severe enough that education cannot be achieved (LRE)

roles and responsibilities of 3 branches of government

• congress/legislative: create/modify programs through LEGISLATION, set budget for discretionary and mandatory health programs, oversee EB implementation of laws

• executive: ACTIONABLE branch of healthcare policies, carries out and implements laws, regulatory change

• judiciary: decides if laws can be implemented, regulates disputes b/w health insurers, investigates fraud

process of bill to legislation

1. congress (house or senate) writes bills

2. committees review bills

3. house reps OR senate must also approve

4. executive branch/president signs into law

legislation vs regulation

legislation (congress) → creates rules or programs

regulation (executive) → explain how legislation is interpreted and implemented

what is the purpose of committees

research issues, revise bills/make amendments, recommend further action

process of regulatory change

• executive branch

  • 1) congress writes bills which may be passed into laws

  • 2) laws are often not detailed enough to execute → executive departments write policies to interpret and enforce laws

• Publish → comment → review → publish

state versus local government

• state

  • professional licensing

  • manage healthcare resources

  • regulated state-managed healthcare programs (Medicaid)

• local

  • share state responsibilities

  • provide resources during shortages or high incidence occurrences

two types of public payers

Medicare and Medicaid

Medicare Parts

A: hospital/acute

B: medical insurance

C: medicare advantage

D: drugs

Medicare characteristics

• eligibility

  • 65+ (older adults)

  • 19-65 with certain disabilities (receiving SSDI for >2 years)

• who administers

  • CMS (fed gov agency)

• strengths/weaknesses

  • (+) broad coverage, consistent eligibility requirements nationwide

  • (-) reimbursement limited by rules, doesn’t cover all costs, strict requirements for some OT services

• Physician Fee Schedule (PFS) → primary Medicare payment, updated yearly, establishes reimbursement for CPT codes

Medicaid characteristics

• eligibility

  • set federally, although states can expand

  • entitlement for low income, children, disability, pregnancy, *some older adults

• who administers

  • federal and state

  • CMS has oversight and state administers based on needs

• strengths and weaknesses

  • (+) coverage for low income, can cover services not covered by medicare, low/no cost for patinet

  • (-) eligibility and benefits vary by state, lower reimbursement rates can make provider participation difficult (low number of providers available)

commercial payers/private insurance

• eligibility

  • usually obtained through employer

  • purchased individually or through marketplace

  • depends on specific plan

• who administers

  • private insurance companies (UHC, BCBC, Priority, Aetna)

• strengths and weaknesses

  • (+) HIGHER reimbursement rates than public, easier to set up and bill, may offer broader coverage plans

  • (-) not all guaranteed to be in network, deductibles/copays/coinsurance vary, may require prior authorization for OT services

professional liability/malpractice insurance

protects for you as practitioner if a ct sues you → consider unique skills

• negligence or improper tx claims

• breach of confidentiality

• license board complaints

what are the two types of professional liability insurance

occurence and claims made

occurrence professional liability insurance

• can be filed and covered through coverage AT ANYTIME if incident occurs during policy period

• higher premium costs since it can cover you for longer

• provides greater protection

claims made professional liability insurance

• can be filed and covered through coverage only when policy is active AND incident is FILED during policy period

• has lower initial premiums but increases with time

general liability insurance

protection from everyday physical risks

• bodily injury

• property damage

• personal and advertising injury

almost always required

insurance term: policy

legal contract between insurance company and policy holder that details the terms under which the insurer will pay for financial losses

insurance term: bundled

professional and general liability insurances are often bundled together

insurance term: claim

bill/request for payment that healthcare provider sends to insurance company after providing services, utilizes CP and ICD-10 codes

insurance term: CPT (treatment) codes

standardized codes used to identify and bill for healthcare services and procedures provided to clients (Physician Fee Schedule for Medicare utilizes CPT codes)

insurance term: ICD-10 (diagnosis) codes

standardized codes used to identify patient’s diagnosis

insurance term: in-network

business has a provider contract established with the insurance company where agreed upon rates for reimbursement, ct typically pays less in-network

insurance term: out-of-network

business does NOT have provider contract established with insurance company, ct may pay more for services OR service may not be covered at all

insurance term: what are the 3 common parties that can be involved

policy holder, dependent, and payer

insurance term: policy holder

person who holds or owns insurance policy (e.g. the client)

insurance term: dependent

a person who receives health insurance coverage through another person’s insurancep lan, usually spouse or children

insurance term: payer

organization or insurance company that PAYS for healthcare services on behalf of patient (e.g. Medicare, Medicaid, BCBS, UHC)

insurance term: allowance

how much a payer (e.g. insurance company or public program) agrees to cover of the total cost of care

insurance term: write-off

• healthcare providers have pre-negotiated fee schedules with insurance companies

• write off is the amount that is NOT COLLECTED from either payer or policy holder → the clinic “eats” the cost

• WHY? → contracted, predictable payments form insurance may be more valuable than charging a higher price w/o insurance that clients may not be able to pay ($100 is better than $0)

insurance term: deductible

specific amount of money the client must pay before insurance covers any of the cost

• PAID FIRST

• AFTER it is met, insurance may begin sharing cost through copay or coinsurance

insurance term: copay

• FIXED amount paid by client directly to healthcare provider

• “set amount each time” → insurance pays remaining covered amount according to plan

insurance term: coinsurance

• a PERCENTAGE (%) of allowance that the client pays to healthcare provider (amount changes based on charge)

• less common in OT, utilized for intensive medical care/conditions

insurance term: health savings account

tax advantaged account to save money for qualified medical expenses

(e.g. deductibles, copays, and certain medical supplies)

traditional practice areas of OT

• approx 80%

• hospital, SNF/LTACH, HH, home and community, schools, EI, mental and behavioral health settings, OP, private practice

focus of traditional practice areas of OT

medical stability, restore to PLOF, establishing/habilitating/rehabilitation

emerging practice areas definition/focus and examples

• settings that OT does not typically work in, but w/skilled perspective we can positively impact population’s well-being

• adaptive sports, animal assisted, community based mental health, postparrtum health, productive aging, refugee resettlement, policy and advocacy, industry (commercial or DME)

service gap

an unmet community need (between what is and what should be) identified via objective and subjective data

how to find and evaluate a service gap

• subjective

  • interview interested parties (listening sessions, focus groups, surveys, direct observations)

• objective

  • 1) health data

  • 2) community level indicators

  • 3) review the evidence base

why are service gaps important

1) gain deeper understanding of community → social structure, culture, history, strengths, and conflict

2) meet and engage interested parties → get community members to brag about assets! can use and/or address them

3) aid in deciding priorities → avoid surprises that may act as a barrier to access

vision definition

• “the dream” → value-based

• what is the ideal outcome → what would happen if issue was perfectly addressed

characteristics of vision

• one or more PHRASES

• easily understood

• broad

• insprint

• EASY TO REMEMBER and communicate

mission definition/characteristics

• WHAT AND WHY, action-oriented, concrete and concise

• 1 sentence

• outcome oriented

• inclusive

vision or mission: meaningful work attainment

vision

vision or mission: safe-at home living

visionv

vision or mission: to promote child health and development through a comprehensive family and community initiative

mission

vision or mission: to create a thriving community through development of jobs, education, housing, and cultural pride

mission

objectives vs strategies broad

objectives → WHAT WILL HAPPEN

strategies → HOW IT WILL HAPPEN

objectives definition and 3 types

• goals stating how much and by when (WHAT)

• 1) behavioral: changing behaviors or outcomes/results of behavior change

• 2) community level

• 3) process: implementing steps to attain the other goals

strategies definition

• how objectives will be met

• 1) providing info and enhance skills

• 2) enhance services and supports

• 3) modify access, barriers, and opportunities

• 4) change consequences of efforts

• 5) modify policies

primary goal of for-profit businesses

GENERATE PROFIT and develop valuable products/services

role of liability for for-profit businesses

guides products/services business provides and supports overall direction

funding for for-profit businesses

bank loans (initially), local investors, revenue from sales/profit

leadership of for-profit businesses

allocated among select group of people, with STAKE in financial success

what are the types of for-profit businesses and differences between them

• sole proprietorships: 1 owner, business owner can be held liable (easiest and least expensive)

• partnership (LP or LLP): 2+ co-owners

• **LLC: protection from risk or professional liability/debt (SEPARATES ENTITIES)

• S-corp: one or more shareholders, can be sold and useful for practices meant to eventually be sold

goal of non-profit business

promote a social cause or advocating for a particular standpoint

role of mission in non-profit businesses

central to the organization

leadership for non-profit businesses

board of directors (at least 3) WITHOUT financial relationship/stake

types of non-profit businesses and differences

• 501c3 → CHARITABLE organization

  • tax deductible, CANNOT lobby or make political endorsements

• 501c4 → community SOCIAL WELFARE organizations

  • MAY use political lobbying activities to advance

  • “every 4 years I can vote in presidential election”

what is the registering entity in Michigan

LARA

skilled versus maintenance OT

• skilled: focus is improvement and to produce change in client through eval, intervention, and discharge lens

• maintenance: focus is NOT to increase or rehabilitate, simply maintain

  • e.g. contracture prevention

2 service delivery types of skilled OT services

indirect and direct

direct skilled OT services

• completed in direct contact w/ clients and families during in-person meetings, group sessions, and telehealth and mHealth interactions

• skilled therapy to produce change in client towards function based continuum

indirect skilled OT services

services such as consultation to entities such as teachers, school systems, participation on multidisciplinary team, and community planning agencies, and advocacy on behalf of their clients

payor characteristics: commerical insurance

• easier to setup and bill

• higher reimbursement than public

• may respond and pay out quicker

payor characteristics: public insurance

• laborious paperwork, steps, and long timelines

• lowest reimbursement

• most equitable

client attraction activities and examples

• things a business does to attract potential clients and encourage them to use its services

  • marketing and advertising

  • community outreach and workshops

  • networking and nurture relationships with referring parties

scheduling considerations for private practice

• allow for managerial AND clinical tx time

• fee schedule: fee schedule is a list of predetermined reimbursement rates for healthcare services, including OT CPT codes. The CPT code tells you WHAT you did; the fee schedule tells you HOW MUCH you get paid.

• net income

• weekly work hours available

• endurance

• administrative responsibilities

what to track for quality management

• clinical outcomes and standardized data

• standardized clinical and administrative systems

• regulatory and compliance

• patient engagement and experience management

What is the PDSA cycle

plan do study act cycle helps track efficacy and promote quality management,

• multiple cycles may be in action at one time OR across time

action steps in P of PDSA cycle

PLAN PRODUCE EXECUTE

1) I plan to

2) I hope this produces (SMART GOALS)

3) steps to execute

action steps in D of PDSA cycle

1) execute plan

2) OBSERVE what happens

• did everything go as planned?

• what do I need to modify?

action steps in S of PDSA cycle

1) compile DATA

2) ANALYZE results

• what did you learn?

• did you mean measurable goal?

action steps in A of PDSA cycle

1) CONCLUSIONS

• worked → ready to implement?

• didn’t work → what might you do differently next cycle?

annual strategic management goals

reassess goals, market assumptions, and annual work plans to aligh with budgeting and changing conditions

strategic management every 3-5 years goals

examine long-term vision, complete overhaul

clinical supervision and how

required to be provided to certain trained participants as part as OT service delivery process

• collaboration

• consider practice settings, needs of clients, supervisor/supervisee experience and training, check health insurance and state licensing requirements

OTA supervision

• follow state licensure guidelines

• OTs are ultimately responsible for supervision

• OTA may not direct eval process (can contribute!)

• OTA may provide services where competence has been observed

administrative supervision

• involves tasks such as addressing staffing issues, ensuring facility compliance, or caseload assignment

• provided outside the service delivery process and may involve health care providers other than OTPs

frequency factors for supervision

• experience level

• competence and performance

• complexity of clients

• risk and safety

• types of services/setting

• organizational and regulatory requirements

supervision methods

• make a plan together, before assessment (preferably upon hiring!)

  • observation

  • co-treatment

  • discussions

  • teaching

  • quarterly or annual checklist of steps with observed assessment

what two things do you need to bill for OT services

EIN/EID and NPI1 and NPI2

NPI1

identifies an individual/professional healthcare provider for billing, stays the same

NPI2

identifies a group or organizational for billing

CAQH

register with CAQH to credential and become in-network with insurance companies

LARA

where you register your business name

house committees

• WEA

• ways and means → medicare part A

  • “ways to pay your hospital stay”

• energy and commerce → medicaid

  • “ENERGY helps people in NEED”

• house appropriations → sets budget for federal healthcare programs

  • “Appropriations APPROVES $”

senate committees

• FHA

• finance → oversee Medicare, Medicaid, and most of ACA

  • ‘finance insurance programs’

• health, education, labor & pensions → public health service

  • “HELP health”

• appropriations → sets budget for discretionary programs

  • “appropriations approves $”