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23 Cards in this Set

  • Front
  • Back
What is the Center for Medicare and Medicaid Services (CMS)?
The federal agency that develops rules and regulations pertaining to federal laws of Medicare and Medicaid.
What is the Occupational Safety and Health Administration (OSHA)?
A federal agency that sets and enforces standards related to safety (BBP, handling infectious materials/blood/hazardous substances, operating machinery)
What is the voluntary accrediting agency JCAHO?
The Joint Commission on Accreditation of Health Care Organizations.

Voluntary agency that accredits health care facilities according to its own standards and conditions. Accredits all types of rehab settings (hospitals, SNF, HHA, LTC, hospice, HMO/PPos, physician's networks).
Payment for OT Services:
Deductible, Diagnosis Code, Diagnostic related groups (DRGs), Health maintenance organization (HMO), Per diem, Preferred provider organization (PPO), Prospective payment system (PPS)
Deductible: the amount a patient must pay to a provider before the insurance benefits will pay.
Diagnosis code: a code that describes a patient's medical reason or condition that requires health service.
DRGs: the descriptive categories established by CMS that determine the level of payment at a per case rate.
HMO: the most common form of managed care. Maintains control over services by requiring enrollees to see only doctors within the HMO network and to obtain referrals before seeking specialty or ancillary care.
Per diem: a negotiated, per day fee for service. Typically used for inpatient hospital stays and SNFs.
PPO: a form of managed care that is similar to an HMO but usually offers a greater choice of providers. As choices increase, percentage of payment decreases.
PPS: the nation-wide payment schedule that determines the Medicare payment for each inpatient stay of a Medicare beneficiary based on DRGs.
Medicare: Eligibility
1. Persons 65 years or older.
2. Individuals with permanent kidney failure, black lung disease, and/or other long-term disability specified in the law.
3. Persons who have been on some social security program for 24 months.
Medicare Part A
- Pays for inpatient hospital, SNF, home health, and hospice care.
- Part A is automatically provided to all covered by the Social Security System that meet the eligibility criteria.

- Services provided in acute care hospitals receive a prospective, predetermined rate based on DRGs.
- It is a fixed amount for patient care regardless of LOS or number of services provided.
- Treatment supplies (AE, splints) are included.

Part A services have specific time limits and require deductible and coinsurance payments.
Medicare Part B
- Pays for hospital outpatient physician and other professional services including OT services provided by independent practitioners.
- Considered a Supplemental Medical Insurance Program, so must be purchased by the patient, usually a monthly premium.
- No specific time limit, requires 20% co-pay.
Medicare Criteria for Coverage of OT Services
- Service must be reasonable and necessary for treatment of the patient's injury or illness.
- There are no diagnostic restrictions for coverage.
- OT must result in a significant, practical improvement in the patient's level of functioning with a reasonable period of time.
What is the difference between Part A and Part B?
- The frequency in which the patient receives services.
- Inpatient Part A requires services for a min of 5 days per week.
- Part B typically covers 3 days per week outpatient services.
What does Medicare NOT cover?
Chronic illness, long term supportive care, maintenance programs, or all medical expenses incurred when ill.
Discuss OT in SNF.
- Covered if the pt. requires skilled nursing or rehab (OT, PT, ST) on a daily basis (min 5 days/week).
- Reimbursement based on RUG levels
- Reimbursement provided for the designing of a maintenance plan and the occasional re-evaluation of the plan's effectiveness.
- NO reimbursement for carrying out the maintenance plan.
- Evaluation and training of caregivers considered part of the design and re-evaluation of a maintenance plan.
- Must document the competence of caregivers to carry out the maintenance plan before discharge from OT.
Discuss OT in Home Care.
- Covered if the client is homebound and needed intermittent skilled nursing, PT, or ST before OT began. OT can continue after need for the others has ended.

You must complete the Outcome and Assessment Information Set (OASIS) to verify eligibility for Medicare Home health benefits, need for home care, and to plan for rehab and discharge.
- Initial OT eval must be complete within 48 hours of referral or 48 hours of person's return home.
Homebound Criteria?
- Person not able to leave home
- If they leave it requires "considerable and taxing effort"
- Person may leave home for medical appointments and non-medical short-term and infrequent appointments.
- The need for adult day care does not preclude a person from receiving home health services.
Reimbursement for OT in Home Care?
- Prospective Payment System (PPS).
- Does NOT pay for DME.
- Payment is per episode: 60 day period.
Discuss OT in Hospice Care.
- Provided to persons who are terminally ill (less than 6 months to live).
- OT role: assist client to maintain functional skills and ADL performance and/or control symptoms.
- OT covered as outpatient service when provided by hospital, SNF, HHA, rehab agency or clinic
Discuss Durable Medical Equipment under Medicare Coverage.
- Rental or purchase expenses for DME are covered if used in the patient's home and if necessary and reasonable to treat an illness or improve functioning.
- Physician's prescription is needed, must include diagnosis, prognosis, and reason for DME need.
What is the Criteria for DME?
-Repeated use can with withstood.
- Primary and customarily used for a medical purpose (i.e. walker, wheelchair)
- Generally not useful to a person without injury or illness.
- Self help items, bathtub grab bars, and raised toilet seats are NOT reimbursable b/c other people can use them, and they are not considered medically necessary.
What is Medicaid?
- A state/federal health insurance program for persons with income below an established threshold and/or have a disability
What are the mandated services that Medicaid must provide?
- Inpatient and hospital services
- Outpatient (lab work, x-rays, skilled nursing) and physicians' services
- Home health
- Early periodic screening diagnosis, and treatment services (EPSDT) for persons 21 years and younger
- Services identified as needed to treat a condition during EPSDT (including OT)
- SNF rehabilitation (if that facility receives Medicaid)
What are the optional services that Medicaid can choose to provide as needed?
- OT, PT, ST
- Services provided by independently practicing licensed professionals (psychs, psychiatric social workers, etc.)
- Targeted case management
- Prescription, medication, dental, eyeglasses
- Crisis response services
- Transportation
- psychiatric inpatient services for persons under 21 or over 65.
- Related services provided by schools to children with disabilities.
What is Workers' Compensation?
- A program that is designed to compensate employees who have job-related illness or injuries.
- Primary focus: rehabilitation and disability management to return the person to gainful employment.
- It is funded jointly by individual employers or groups of employers and state governments.
- Coverage varies from state to state.
Explain Supplemental Security Income (SSI).
A Federal income supplement program funded by general tax revenues (not Social Security taxes)
- Designed to help aged, blind, and disabled people 65 years and older with limited income and resources - Blind or disabled children may also get SSI
- Provides cash to meet basic needs for food, clothing, and shelter
Explain Social Security Disability (SSD/SSDI).
Social Security Disability Insurance pays monthly benefits to you and certain members of your family if you are "insured," meaning that you worked long enough and paid Social Security taxes.
- You are no longer able to work due to a significant illness or impairment that is expected to last at least a year or to result in death within a year.
- Benefits are based on the disabled worker's past earnings and are paid to the disabled worker and to his or her dependent family members