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86 Cards in this Set

  • Front
  • Back
To what time period do we trace modern health insurance? ***
the late 1840s
What did the Massachusetts Health Insurance of Boston cover? ***
group policies for accident insurance related to travel by rail or steamboat
When did sickness insurance come about? What did it provide? ***
- early 1910s

- a type of disability insurance plan to provide income replacement in the event of illness
When did health insurance come about? By whom? ***
- 1929

- Dallas-based teachers formed a partnership with an area hospital
How was the first health insurance set up? What was it called? ***
- an agreement between Dallas-based teachers and a local hospital formed a partnership to provide a set amount of sickness and hospitalization days in exchange for a fixed, prepaid fee

- Blue Cross
(Blue Shield was later formed to pay physicians)
What is “insurance”? ***
- either an act or business

- legal means of protecting a person (or property) against loss or harm arising out of specified circumstances in return for payment
What is “financing” with respect to insurance? ***
the flow of money from enrollees, employers, or government to a health plan
What is “reimbursement” with respect to insurance? ***
the flow of money from a health plan to a provider
List four methods of financing insurance. ***
(She definitely said this was a test question!!)
- out-of-pocket
- individual private insurance
- employment-based private insurance
- government-financed health care
How is out-of-pocket health insurance financed? Upon what is the financing based? ***
- via direct payment from the recipient of the service

- financing is based upon fee for service

- e.g., you get stitches in your hand at the Texas MedClinic and pay by credit card when you leave
How is individual private insurance financed? ***
subscriber pays out-of-pocket monthly premium to a health insurance company in exchange for medical services
What is a deductible? ***
the designated amount a subscriber must pay to the healthcare provider before insurance company contributes any funds
What is a co-payment? ***
the designated (and usually relatively small) amount a subscriber must pay at the time the healthcare service is provided before the insurance pays
What is employment-based private insurance? How is it financed? ***
- health insurance through one’s employer

- financed through contributions of both employee and employer
--- insured usually pays a deductible and co-pays
--- may also pay a premium

- came about partially due to national wage freeze during the Great Depression
What percentage of people have employment-based private insurance? ***
about 61% of those insured
How are employee contributions to employment-based private insurance determined (2 methods)? ***
- experience rating – higher-risk people pay more

- community rating – all pay the same
Name four systems of government-financed health care. ***
(She definitely said this was a test question!!)
- Medicare
- Medicaid
- CHIP
- VA/Military
Name two means of payment for healthcare reimbursement. ***
- retrospective payment

- prospective payment
What is retrospective payment? ***
reimbursement negotiated after the services are provided
What is prospective payment? ***
- reimbursement negotiated before services provided

- the insurance company has a contract with the employer based on the number of members in the plan, types of diagnoses, etc.
Prior to the 1980s, how was most reimbursement conducted? What was the result? ***
- retrospectively

- led to increased cost of healthcare
What does PPS stand for? What is its advantage? ***
- Prospective Payment Systems

- encourages providers to limit services
Name four types of prospective payment systems for healthcare reimbursement. ***
(She definitely said this was a test question!!)
- fee for service
- per visit
- per case or per episode
- capitation
What is fee-for-service (FFS) reimbursement? ***
- like store purchasing (her notes) <-- maybe a la carte would be more accurate???

- based on usual, customary, and reasonable (UCR) fee schedule

- e.g., physical therapist reimbursed for providing hot pack, mobilization, and therapeutic exercise instruction
What is per-visit reimbursement? What is its advantage? ***
- provider is reimbursed a specific amount each time the patient is treated

- discourages over-treatment of patient
What is per-case or per-episode reimbursement? ***
- provider is given one payment for each episode or hospital admission, often based on diagnosis

- e.g., Medicare diagnosis-related groups (DRG) dictate a predetermined fee to be paid to hospitals for each admission
What is reimbursement by capitation? ***
- payment per member per month or year

- one payment is made for each member of the health plan each month or year, regardless of the member’s utilization of services

- healthcare provider may see a profit or loss based on utilization by the membership

- e.g., $50/m/m (X 100) = $50 per member per month X 100 members = $5,000
Why is healthcare so increasingly costly? ***
- people have longer life expectancies
- access and demand
- advances in medical technology

- media intervention (e.g., drug company advertisements)
- prescription drug costs
- malpractice (may be as high as $400,000) <-- the premium for the malpractice insurance?
What is managed care? ***
medical care that:
- is provided by a corporation
- is established under state and federal laws
- makes medical decisions for enrollees instead of physician
- attempts to attain high quality care at low cost
Name three types of managed care systems. ***
- fee-for-service with utilization review
- preferred provider organization (PPO)
- health maintenance organization (HMO)
What is fee-for-service with utilization review? ***
- retrospective payment system
- claim reviewed by the insurance company and reimbursement is made based on what is usual, customary, and reasonable (UCR)
- claims may be denied
What is a preferred-provider organization (PPO)? ***
(She definitely said this was a test question!!)
a system wherein:
- providers agree to provide services for subscribers at negotiated fee-for-service (FFS) rate (usually a discounted rate)
- providers gain referrals
- payment is made retrospectively (usually)
- greater freedom of choice is given to participants
- participants do not need PCP or referrals
What is a health maintenance organization (HMO)? ***
a system wherein:
- subscribers receive services for a fixed price for a given period of time
- a deductible may or may not be required; co-pays are limited
- providers’ reimbursement is bundled (via per diem, capitation, or salary)
- payment is prospective (usually)
Name five types of hospital reimbursement. ***
- payment per procedure
- payment per diem
- payment per episode of hospitalization
- payment per patient/capitation
- payment per institution/global budget
Describe the “payment per procedure” hospital reimbursement method. ***
a fee-for-service model (not common anymore)
Describe the “payment per diem” hospital reimbursement method. ***
hospital is paid a set amount per day, regardless of the number of services provided
Describe the “payment per episode” hospital reimbursement method. ***
- Medicare
- diagnosis determines the amount of payment to the hospital from Medicare (diagnosis-related groups – DRG)

- does not matter where patient goes after discharge
Describe the “payment per patient” hospital reimbursement method. ***
- common with HMOs
- capitation
- hospital gets set amount per month per enrollee whether they are hospitalized or not
Describe the “payment per institution” hospital reimbursement method. ***
- VA hospital
- global budget
- commonly used in some European and Canadian systems as well
- fixed annual sum
How is physical therapy commonly reimbursed? ***
- fee for service (FFS) with usual, customary, and reasonable (UCR) rates

- prospective payment systems (PPS) with preferred provider organizations (PPO) and health maintenance organizations (HMO)—how they get referrals
How is therapy reimbursed in skilled nursing facilities (SNF)? ***
(She definitely said this was a test question—especially RUGS and MDS!!)
- prospective payment system (PPS) after 1997
- Medicare Part A to use Resource Utilization Groups (RUGS III)
- patients are placed into RUG categories (e.g., “high,” “very high,” etc.)
- based on total number of minutes of therapy per week, days of therapy per week, and number and types of therapy (MDS- Minimum Data Set)
- reimbursement is based on RUG category/number of minutes of PT, OT, ST
- looks at cost of staff time
What are the benefits of managed care? ***
- improved efficiency
- providers are more cost-effective
- providers are more accountable for quality care
- compels providers to maintain ethical standards
What is practice profiling? What is the benefit? ***
- making comparisons based on outcomes and identifying areas needing improvement
- referring patients to other providers who can treat more efficiently

- allows more autonomy and alternatives
What are some disadvantages of managed care? ***
- “cookie-cutter” treatment
- patient may be seen as “just another number”
- patient may not get needed care
- more difficult to justify medically necessary equipment
- salaries limited
- medical professionals are managed by business people with $$ as the bottom line
Per the PBS link, how does health care in the U.S. stack up? ***
- $8,233 per person per year spent on health care
- 2.5 times more than most other countries
- 17.6 percent of GDP
What is Medicare? ***
federal insurance program established by Congress in 1965
Who is eligible for Medicare coverage? ***
(She definitely said this was a test question!!)
citizens or permanent residents of the U.S. who are
- aged 65 or older

- under age 65 but
--- disabled
--- suffering from end-stage renal disease (ESRD) or
--- diagnosed with amyotrophic lateral sclerosis (ALS)
and received social security benefits for 24 months
How is Medicare Part A funded? ***
- through social security taxes, employers, and employees
- free to those who are 65 and with individual or spouse having accrued 40 or more quarters of Medicare-covered employment (person or spouse paid in for 10 years)
- coverage can be purchased if individual/spouse has less than 40 eligible quarters
What services are covered under Medicare Part A, and what is the 2013 deductible? ***
- inpatient hospital care
- inpatient skilled nursing facility care
- home health care
- hospice care
- blood (transfusions)
(all services covered must be medically necessary)

- $1,184 per year
How is Medicare Part B funded? ***
- federal funds and beneficiary contribution
What are the 2013 premium and deductible for Medicare Part B? ***
- premium is $104.90 per month (more for higher income beneficiaries), often taken directly from social security payments

- deductible is $147 per year
What services are covered under Medicare Part B? ***
- doctor visits
- outpatient rehabilitation (e.g., PT)
- X-rays
- ambulance transport
- durable medical equipment (DME)
- bone mass density testing
- chiropractic
- eyeglasses
- pap/mammography
- vaccinations
What is Medicare Part C and what does it cover? ***
- Medicare Advantage
- new option with the Balanced Budget Act of 1997
- combines Parts A and B and additional services such as dental care, hearing aids, preventive care, etc.
Who administers Medicare Part C/Medicare Advantage? ***
private insurance companies (e.g., FFS, PPO, HMO)
How may a beneficiary select Medicare coverage? ***
- may choose Part A only, Part B only, Part A and B, or Part C

- may add Part D to any of the above
What is Medicare Part D, and when did it come about? ***
(She definitely said this was a test question!!)
- prescription drug program

- 2006
What is the cost for Medicare Part D? What is the “donut hole”? ***
- anywhere from $2 to $100, with 2013 average of $32

- there is a $310 deductible
- for the next $2840, Medicare pays 75% ($2130) out of cumulative total of $3150 ($310 + $2840)
- beneficiary pays next $4500 out of pocket (to $7650--$310 + $2840 + $4500) DONUT HOLE
- after which Medicare pays 95% of drug cost
What is Medigap? ***
- private insurance
- a secondary policy that supplements Medicare coverage
- not the same as Medicare Advantage (Part C)
- e.g., Humana, AARP
What is Medicaid and how is it financed? ***
- for low-income persons

- through federal and state taxes
What is (S)CHIP and who is eligible? ***
- (State) Children’s Health Insurance Program
- created by the Balanced Budget Act of 1997

- allows states to expand health care to more children (and some parents)
- covers low-income children who are otherwise ineligible for Medicaid but cannot afford private insurance
When did Congress first request medical assistance for families of military members? ***
1884
What is CHAMPUS, and when did it come to be? ***
- Civilian Health and Medical Program of the Uniformed Services

- 1966
What is TRICARE, and when did it come to be? ***
- replaced CHAMPUS
- provides medical care coverage for active duty servicemembers, their spouses and unmarried children; activated Guard/Reserve members; retirees, their spouses, and unmarried children (to age 23 if in school)

- 1988
What is Workers’ Compensation (WC) and when did it come to be? ***
- began in Germany in the 1800s, U.S. in the 1930s

- pays medical expenses and partial loss of wages for workers injured on the job
- WC laws are state-specific
- employer pays premiums
Name two types of tax-sheltered accounts. ***
- Medical Savings Account (MSA)

- Flexible Spending Account (FSA)
What is an MSA? ***
- Medical Savings Account

- tax-sheltered account for paying medical bills
- for self-employed or small-business employees
What is an FSA? ***
- Flexible Spending Account

- tax-sheltered account with premium deducted from before-tax wages
What is COBRA? What is its purpose? ***
- Consolidated Omnibus Budget Reconciliation Act (1986)

- allows individuals to purchase temporary continuation of group health plan coverage if laid off, forced to quit due to illness, fired
- maximum of 18 months of coverage
- for companies with more than 20 employees
For our purposes, what is fraud? Give some examples. ****
- intentional deception or misrepresentation made by an entity or individual, knowing that it could result in unauthorized benefit to an individual, entity, or another party
- must be able to prove INTENT

- e.g., billing for services not rendered, falsifying documentation, unbundling charges, up-coding
For our purposes, what is abuse? Give some examples. ****
- improper or harmful procedure or method of doing business that contradicts accepted business practice
- not as serious as fraud
- intent cannot be proven

- e.g., unnecessary services, unfair pricing
What is the purpose of the Joint Commission? ***
- evaluates compliance of healthcare organizations
--- hospitals
--- MC plans
--- home care organizations
--- nursing homes
--- assisted living facilities
--- ambulatory care providers
--- clinical laboratories

- formerly known as JCAHO, pronounced “jay coe”
How did the BBA affect reimbursement for therapy under Medicare Part B? ***
the Balanced Budget Act of 1997:
- increased therapy services included in the limits
- expanded the settings in which the limits would apply
How did the lack of an Oxford comma in the wording of the BBA affect reimbursement for therapy under Medicare Part B? (She didn’t really explain if this was intentional or not.) ***
- the Balanced Budget Act of 1997 provided for reimbursement for “OT, PT and SLP” instead of for “OT, PT, and SLP”
- interpretation was that PT and SLP were combined
- one $1,500 cap for OT, and one $1,500 cap to be split between PT and SLP
What were the Medicare Part B therapy caps put into effect by the BBA? ***
- initially $1,500 in 1999

- this meant $1,500 for OT, and $1,500 for PT and SLP together
Under the BBA, who may provide therapy? How is reimbursement provided? ***
- in 1999 physician assistants, nurse practitioners and clinical nurse specialists were permitted to provide therapy services within the scope of their state licenses

- the Balanced Budget Act imposed financial limits of $1,500 for PT and SLP together and a separate $1500 for OT

- the limits applied not just to PT and OT in private practice, but all those providing therapy services including physicians, PA,NP and CNS

- the limits are tied to the Medicare Economic Index, so that when they were re-imposed in 2003 (after being capped from 2000-2002), the limit was $1,590
What are “therapy services” as defined by the BBA/Medicare Part B? ***
- include only outpatient PT, OT, and SLP in outpatient settings

- CAP DOES NOT APPLY FOR INPATIENT!!

- other services such as psychotherapy or medical nutrition therapy are not affected by the limitations on outpatient rehabilitation therapy services

- most of the rules that apply to outpatient therapy services are in the Medicare Benefit Policy, Manual Chapter 15, sections 220 and 230
What types of settings are included in/labeled as “outpatient therapy services,” reimbursable under the Medicare Part B cap? ***
- private practices of therapists, physicians and non-physician practitioners
- outpatient rehabilitation facilities/rehabilitation agencies
- comprehensive outpatient rehabilitation facilities
- skilled nursing facilities (SNF) providing service to outpatients or residents who are not in covered stays, and
- home-based therapy from home health agencies for outpatients who are not getting Medicare-covered home health care (under Medicare Part A)

- that is, any setting not connected to a hospital
(except, per http://www.medicare.gov/what-medicare-covers/part-b/more-information-about-therapy-limits.html: Until October 1, 2012, the outpatient therapy services provided in a hospital are exempt from the therapy cap limits. Starting October 1, 2012, however, the exemption ends and the outpatient therapy caps will apply to therapy services you get in an outpatient hospital department or hospital emergency room and will count toward the therapy cap limits.)

- only services that are paid using the Physician Fee Schedule are subject to the caps
- no cap is applied to therapy services provided to hospital patients, or where Prospective Payment Systems pay for services (SNF-PPS, IRF-PPS, HHA-PPS plans of care).
What services are excluded from Medicare Part B therapy limits? ***
- outpatient therapy services billed by HOSPITALS are not included in the limits

- this means most people covered by Medicare may receive medically necessary, covered, outpatient therapy services even after reaching the limit, if they receive these services from an outpatient HOSPITAL department
What happened to the caps on outpatient therapy reimbursement under Medicare Part B in 1999? Between 2000 and 2002? In 2003? In 2004-2005? ***
- caps implemented in 1999 at $1,500 each for OT and for PT/SLP
- Congress put a “hold” on the limits for 2000-2002
- “hold” continued for part of 2003, then cap of $1,590 implemented
- “hold” placed on the limits for 2004-2005 as well
What happened to the caps on outpatient therapy reimbursement under Medicare Part B between 2006 and 2013? ***
- they increased every year (tied to the Medicare Economic Index) from $1,740 in 2006 to $1,900 in 2013

- she gave the caps for each year, but only expects us to know the 2013 cap of $1,900

- again, this is $1,900 for OT and $1,900 for PT/SLP (in 2013)
How are Medicare providers and consumers notified of changes in the caps? ***
if Congress changes the statute, Medicare will:
- post notice on www.cms.hhs.gov/providers/therapy
- inform contractors in writing

- Medicare contractors will then post the information on their websites
Describe Medicare Part B and beneficiary payments for therapy services in 2013. ***
- numbers apply to persons with Medicare who obtained outpatient therapy services from settings that are limited
- they do not apply to services from a hospital (although as of 1 Oct 2012, they apparently do)

- beneficiary pays the $104.90 monthly premium (usually taken directly from Social Security payments)
- beneficiary pays the $147 deductible (deductible for 2013)
- beneficiary pays a 20% co-pay of the remainder (up to the cap)

- Medicare Part B pays 80% of the remainder (up to the cap), after the deductible and co-pay

- beneficiary covers expenses beyond the cap

- e.g., for $2,000 in PT/SLP in 2013, with deductible already met:
- beneficiary pays 20% of $1,900 cap ($380)
- Medicare pays remaining 80% ($1,520)
- beneficiary pays remaining $100 over the cap

e.g., for $1,000 in PT/SLP in 2013, with deductible NOT met:
- beneficiary pays $147 deductible
- beneficiary pays 20% of remaining $853 ($171; $318 total when added to $147 deductible)
- Medicare pays 80% of remaining $853 ($682)
- if more PT was needed, Medicare would pay 80% of the remaining $900 to the cap
What is an MSN? For what is it used? ***
- a Medicare Summary Notice – sent by mail to beneficiaries every 3 months when services are used
- a summary of all services/supplies that providers and suppliers billed to Medicare during the quarter, what Medicare paid, and what you may owe the provider

- starting in July 2003, each MSN included a message about the limits and described the options in the general information section

- the message was updated in 2003 and again in 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013.
Who may access the accrued amount of therapy services? How? ***
- Medicare contractors, providers, and suppliers

- from the ELGA and ELGB screen inquiries into CWF or the HIPAA 270/271 eligibility inquiry transaction
- providers may also access HIQA
What are the Medicare supervision requirements for PTA students working with Part A patients? With Part B patients? ***
- Part A – student can have general supervision (PT in the building, reachable by phone)

- Part B – student may assist or participate in treatment provided by a PT/PTA
- the treatment is not reimbursable if student treats the patient solo
- student will not write in the chart

- General (not required to be on-site; phone)
- Direct (must be on-site; PT checks in each visit)
- Direct Personal Supervision (PT, or PTA where permitted, must be physically present the entire treatment and must be focused on patient, not doing other things; basically a co-treatment)
- Line-of-sight (not in APTA definition, but PT in same area and can see the treatment; Medicare)
What are the Medicare supervision requirements for PTAs working with Part B patients? ***
- home health – general supervision (PT in the building, reachable by phone)
- SNF – general supervision
- hospital inpatient and outpatient – general supervision (defer to Practice Act, this is what TX says)

- private practice – direct supervision (in the same office suite and immediately available to provide assistance when necessary)
- physician’s office – direct supervision


- General (not required to be on-site; phone)
- Direct (must be on-site; PT checks in each visit)
- Direct Personal Supervision (PT, or PTA where permitted, must be physically present the entire treatment and must be focused on patient, not doing other things; basically a co-treatment)
- Line-of-sight (not in APTA definition, but PT in same area and can see the treatment; Medicare)