Reimbursement - Home Health

Front 1

Name the conditions a pt must meet to be eligible for home health care under medicare

Back 1

1. Medicare B
2. Doc ertifies need for service and establishes POC
3. B meets Medicare's def of home bound
4. Care must be provided in home
5. Services provided by medicare-certified home health agency
6. Pt needs skilled nursing or skilled therapy services

Front 2

Will medicare pay for a one time visit for home health?

Back 2

Nursing = no
Therapy = yes

Front 3

Where must home health therapy be conducted?

Back 3

In the home!
This may be an assisted living facility if there is where pt lives
NOT adult day care

Front 4

Medicare definition of home bound

Back 4

Coniditon that restricts the ability of the individual to leave his or her home except with the assistance of another individual or the aid of a supportive devise (such as crutches, a cane, a wheelchair or a walker),
If the individual has a condition such that leaving his or her home is medically contraindicated.

Front 5

What is the case mix index? What are teh 3 groups it divides shit into?

Back 5

Scale that measures the relative diff in resource intensity among diff groups in a clinical model
Clinical (pt's problems)
Fxt status (ADLs, AMB, transfers)
Services (ST, PT, OT, nursing, RD, etc)

Front 6

Conditions of Participation

Back 6

Minimum health and safety standard that a HHA must comply with in order to qualify for reimbursement under medicare

Front 7

Explain consolidated billing with a HHA

Back 7

When a pt is under HH, ALL services and supplies are included in the PPT spisodic rate
This means HHA is responsible for wound dressings, catheter supplies, Outpt therapy, drugs, etc

Front 8

What two things is the HHA not responsible for with consolidated billing?

Back 8

Osteoporosis drugs
DME

Front 9

What is an "episode"

Back 9

This is how Medicare pays HHA - based on a 60 day episode

Front 10

How many HHRG's are there? How many visits must a pt have to be grouped into an HHRG?

Back 10

153
Need 5 or more visits or else LUPA

Front 11

What in the hell is LUPA?

Back 11

Low utilization payment adjustment. Occurs when HHA does not deliver 5 or more visits to the pt.
HHA is paid/visit and the money blows

Front 12

How much co-insurance does a HH pt pay?

Back 12

None son

Front 13

What is OASIS ?

Back 13

Outcome and Assessment Info Set
Interview and observation
Critical to reimbursement as well as measuring outcomes, pt assessment, care planning, case mix reports, datacollection, and performance improvement areas.

Front 14

What is home health compare?

Back 14

Lets consumers see the quality outcomes from dif HHA so they can choose the best one

Front 15

What happens if HHA does not report quality standards on the OASIS?

Back 15

2% reduction in payment

Front 16

Outliers?

Back 16

Payments made to HHA in addition to the 60 day case mix
Give 'wage adjusted episode payments' for services that incur unusually large costs due to home health needs

Front 17

PEP?

Back 17

Partial Episode Payment
Partial paymnet adjustement given to HHA when a pt has been d/c and re-admitted with a new SOC within the original 60 day episode
So HHA doesn't get paid for a brand new 60 day episode

Front 18

RAP?

Back 18

Request for Anticipated Payment
Give me my money
SOC completed, HHRG calculated - the HHA uses this to request paymnet from MEdicare based on anticipated delivery of services

Front 19

How much does medicare pay for the RAP?

Back 19

60% up front
40% when the goods have been delivered and the episode is complete with d/c

Front 20

What MUST a referral include in order to be accepted by a HHA?

Back 20

Doc's order
Diagnosis
Pay source
Continuity of care signed by doc if coming from hospital, SNF, or rehab facility

Front 21

Whats nice about having Medicaid if you are a pt?

Back 21

Pt does not need to be homebound
They pay for custodial care so pt could be getting skilled and non-skilled services

Front 22

Would you rather have medicare or commercial insurance when it comes to HH?

Back 22

Medicare
Commercial usually have more restrictive criteria to be allowed to get HH (ie. AMB less tha 60 ft)

Front 23

What is the HHPPS based on?

Back 23

National standardized 60 day episode payment adjusted for case mix index and wage index.

Front 24

Give some examples of "clinical" componenet of this HHRG domain

Back 24

Diagnoses
Vision, pain
Wound, dyspnea, incontinence
dementia
YOUR PROBLEMS

Front 25

What happens if the nurse fucks up and puts pt in a lower HHRG then he should be?

Back 25

It's all good.. you'll get reimbursed for all your visits at the end when you receive your 40%

Front 26

4 things teh Clinical Prediction of Reasonable and Necessary Rehab Visits depend son

Back 26

Demographic factors
Diagnoses
Co-morbidities
Oasis Walk fxt (current vs prior level of AMB)

Front 27

Difference between early and late episodes? What do we care?

Back 27

Episode number 1 or 2 vs. 3 or higher in a series
You get paid less for later episodes cuz ya ain't doin ya job

Front 28

What is the new Therapy Case Mix adjustments?

Back 28

0-13
14-19
>20

Front 29

What is the "S" group?

Back 29

A subcomponent of the Therapy Tiers where you get paid a lilttle bit more for increased days with in a tier
ie. 0-13 days is one tier
S groups are between 0-13 that give ya a lil more for more visits

Front 30

Range of reimbursment rates for the Final HHRG?

Back 30

1200 to 6600 to provide service over a 60 day period

Front 31

Prereq's for submitting the RAP?

Back 31

Verbal order or signed continuity from physician
One billable visit

Front 32

What things can influence the final 40% payment medicare gives to the HHA?

Back 32

Transfers
Incorrectly projecting the number of therapy visits

Front 33

Certification vs. recertification?

Back 33

Cert - must have signed 485 POC prior to the final bill
Recertification - get 50/50 instead of 60/40 cuz ya aint doin ya job

Front 34

2 scenarios for a PEP?

Back 34

Pt transfer from one HHA to another
Pt readmitted to same agency within 60 days of inital SOC

Front 35

SCIC - what is this and what does it result in?

Back 35

Suddent change in condition
Have a stroke and this causes THerapy Threshold Adjustments and less pay

Front 36

Who are RACs? Not that RAC

Back 36

Recovery Audit Contractors who get paid to find incorrect/fraudulent billing

Front 37

What is the CARE instrument?

Back 37

Standardized Pt Assessment Tool that will be used by ALL post-acute settings with the goal of standardizing pt assessment info from all post acute settings

Front 38

Whats the deal with this Home Health Pay-for-Performance Demonstration?

Back 38

Incentive pool to be sweet
If you are sweet, you'll get reimbursed more
ie. less hospitalizations, reported improvements in bathing, toileting, transferring, etc.

Front 39

What is the US Govt Accountability Office (GAO) report recommending?

Back 39

Background checks
Post pay audit reviews

Front 40

HHCAHPS

Back 40

Consumer Assessment of Healthcare Providers and Systems
Surveys pt and makes it public via Home Health Compare

Front 41

What is the Value Based Purhcasing (VBP) Inititative?

Back 41

Using OASIS C and HHCAPS to translate value of healthcare services in money
Measure value based on clinical and financial outcomes