Transcript Document

Health Care Systems,
Medicare & Medicaid
PTP 783 Module 3
History of US healthcare
1935: Congress began to look in to
a national healthcare program
1949 (Truman) administration
– Controversial, but later targeted to
just elderly
1965 House Ways & Means
Committee brought forth 2
amendments to the SSA: Titles 18
Medicare & 19 Medicaid
Evolution of Geriatric
Reimbursement:
Medicare
Title 18 of Social Security Act 1965
– Provide protection against cost of
hospital and related care aged >65
who are entitled to SS retirement
benefits – Medicare A
– Permit >65 y.o. to purchase protection
against the cost of physician services,
one-half of the cost to be paid by the
federal government – Medicare B
Evolution of Geriatric
Reimbursement:
Social Security
Title 19 of Social Security Act
– Federal government matches cost of
medical assistance for medically
indigent aged person for all needy
persons for whom the state is receiving
federal grants - Medicaid
Who Opposed the expansion of
health care coverage?
AMA
AHA
Insurance reps
Management special-interest
groups
The political right
Sounds familiar?
Evolution of Geriatric
Reimbursement
Balanced Budget Act 1997
– Effected PT Reimbursement in
– SNF
– Home Health
– Hospitals
– Outpatient
– Medicare choice Plans
– Inpt Rehab spared for about 3 years
The “Upside” to the Balanced
Budget Act
Anti Fraud Laws
– Billing for services not rendered
Anti Abuse Laws
– Billing for services not considered
“reasonable and necessary”
– Appropriate documentation is a must
– Skilled service requirement
Medicare & Medicaid
CMS: Centers for Medicare and
Medicaid Services
Purposes:
– To establish policies on coverage,
eligibility, & reimbursement
– To establish standards for providers
– To provide program administration
– To monitor the performance of
contractors and states
Medicare is made up of:
Part A services: hospital, in-pt
Part B services: out-patient
services
Part C (Medicare Advantage plans)
HMOs
Part D: Medications
Do you have to be over 65 to
have Medicare?
NO
Stipulations:
– Over 65 who is eligible for Social
Security
– Railroad retirement benefits
or
– Disability benefits for greater than 24
months
– Chronic renal disease
Why is it important for physical
therapists to be familiar with the
rules defining skilled and
nonskilled services for Medicare
recipients?
Skilled Rehab Services covered
by Medicare:
o
o
o
o
o
o
o
o
o
o
Evaluation
Reevaluation
Ther ex
Manual therapy
Gait training
ROM
Ultrasound, E-stim
Diathermy
Paraffin
Whirlpool
o Transfer training
o Establishing a FMP
o Restraint
evaluation
o Orthotic training
o W/c training
o Pt & family training
o Vasopneumatic
devices
o Infrared * (depends on
intermediary)
Medicare Part A coverage
 Hospital
–
–
–
–
First 60 days pay all but $1184 (deductible)
61-90 days pay all but $296/day
91-150 days pay all but $592/day (lifetime reserve days)
>150 days Medicare pays nothing
 SNF
– Medicare pays first 20 days at 100%
– then 80% from day 21-100 up to $148/day
– after 100 days Part A services pays nothing
 Home Health
– Pays 100% medically necessary services, and 80% DME
• Must be home bound and under physician’s care
 Hospice
– Pays 100% except limited cost sharing for meds and respite care
(5% discount off Medicare approved rate)
– Has to be a Medicare approved hospice inpt facility (not the pt’s
home or a SNF that is not approved)
 Blood
– Pays for first 3 pints furnished by hospital or SNF during a
covered stay
Other issues with Medicare
Benefit period: begins on day 1 of
hospital and ends after 60 days of
wellness after d/c from hospital or
SNF.
Medicare & SNFs
 For Medicare coverage with PART A
services the pt must have
 A 3-day qualifying stay in the hospital
 Require skilled services (PT, OT, ST, nursing)
 If the pt is not directly admitted to a SNF after
d/c from the hospital then he/she has 30 days
to be admitted to the SNF for Part A services to
cover her stay.
 Care at SNF must be for the same dx as what
pt was hospitalized for
Prior to PPS (1997) SNFs were
paid in 3 different categories
1. Routine costs: room, nursing services,
medical supplies, psyc & social
services, & use of facility equipment
2. Ancillary costs: therapy, meds, labs
3. Capital related costs: cost of land
*now it all bundled into one per diem rate
Medicare Assessments in SNFs
Medicare requires SNFs to do periodic
assessments throughout a patient’s stay
to determine level of payment.
AKA: PPS (Prospective Payment System)
Assessment Name
End Date
Days Covered
# of Days Authorized for Payment
5-Day Assessment
1 to 5
1 to 14
14
14- Day Assessment
11 to 14
15 to 30
16
30- Day Assessment
21 to 29
31 to 60
30
60-Day Assessment
50 to 59
61 to 90
30
90-Day Assessment
80 to 89
91 to 100
10
Medicare RUG levels
During those assessment periods
the patient must fit into a RUG
level (Resource Utilization Group)
Category
Minutes
Disciplines & days (within a 7 day period)
Ultra High
720
At least 2 disciplines, one is at least 5x/wk (other
at least 3x/wk)
Very High
500
At least 1 discipline for at least 5 days
High
325
At least 1 discipline for at least 5 days
150
At least 5 days of any combination of the three
disciplines
Medium
Low
45
At least 3 days of any discipline combination and
2 or more nursing rehabilitation services for at
least 15 minutes
Medicare Part B
 Deductible: $147/yr
 Medical Expenses
– PT Services
– 80% of hospital based services
– All other PT clinics subject to therapy cap $1900
 Clinical Laboratory Services
• Pays 100%
 Home Health
– 100%, DME is 80%
 OP Hospital Treatment
– 80%
 Blood: 3 pints ‘free’, afterwards covered at 80%
Reimbursement for PT services:
Outpatient – Medicare Part B
$1900 cap for non-hospital PT
(2013)
– On January 1, 2013, Congress passed
the American Taxpayer Relief Act of
2012 which extended the Medicare
therapy cap exceptions process until
December 31, 2013
Part B Premium
Part B services may be used
when
 There has been a decline in functional
level due to disease, injury, or condition
 May or may not have been hospitalized
 Not covered currently by Part A services
 Decline can be due to:
 Pain with decreased functional level, exacerbation
of chronic condition with functional decline,
exhaustion of Part A services, but still requires
further PT services.
Medicare payment for home
health services
 PPS: predesignated payment that varies
with health condition & care needs
 Agencies provided payment for each 60day episode of care.
 Can have more than one 60 day period
 Adjustments are made for significant
changes in condition or pts with fewer
visits
 OASIS if under Part A benefits
Quality Measures in Home
Health
 Improvements in mobility:
– Walking or moving around, transfers in/out of
bed, less pain while moving around
 ADLs
– Bladder control, bathing, correct use of meds,
dyspnea levels
 Long-term outcomes
 Patient medical emergencies
– Hospital admissions, urgent medical care
Managed Care by Medicare
Also called Medicare Advantage
Plans
MCOs control access to health care
services and create an system that
works on efficiency of payment
As with most MCOs bureaucracy
results in lapse of time from referral
to treatment which impacts
outcomes and complicates
continuity of care.
HMO pros/cons
 Pros:
– Minimal paperwork
– Additional services provided at little to no cost
(hearing aids, eyeglasses, dental care)
 Cons:
– Gatekeeper: limits PT treatments
– Specifies which providers can be used
– Income received by HMO is on a prepaid basis:
so increased incentive to minimize costs.
PT Practice Concerns
Regarding Medicare
 Need to be “enrolled”
 Obtain a provider number
 Need to accept fee schedule
 No waiving copays
 Patient may have coordination of
benefits with MC primary, other
provider secondary
In order for Medicare to pay
physical therapy services must
be:
Reasonable
Necessary
Skilled
Appropriate frequency & duration
Expectation that the condition will
improve
Physician must sign the
certification every 90 days
Medicaid
 Differs state by state
 Low income (at or below 133% of national
poverty level)
 May have to ‘spend down’ to be eligible
 Spousal Impoverishment Plan: spouse can
retain a relatively generous amount of
income and assets
 Funded by both federal and state levels
 Does not pay for MOW, unless pt has a
waiver
 In some states: PT is an ‘optional’ benefit
for Medicaid recipients
Medigap insurance policies
 Created to gap the payment necessary
when part A or B services are not covered.
 Usually covers the 20% copayment that A
or B does not cover
 Expensive
 Questionable future due to high costs
 Medicare only pays 80% of allowable
charges, so many providers charge more
than this: leads to need for Medigap or
other coverage
Veterans Benefits
Veterans Administration (VA)
provides a program that covers
health care for war veterans
through over 153 VA hospitals, 773
outpatient centers and 100 VA
nursing homes & contracts with
community facilities.
May be able to get specific services
At times wait can be long and
distance traveled is great.
Other Long Term Care Policies
in creation
35 states are creating their own
policies
Hawaii: Family Hope program:
program to finance long term care.
Medicare Fraud & Abuse
Fraud occurs when someone
intentionally falsifies information or
deceives the Medicare Program.
Abuse occurs when doctors or
suppliers do not follow good
medical practices that can result in
unnecessary costs to Medicare
Medicare and the Future
 Pay for Performance- PQRI
– Will soon be paid for performance of patients. Gcodes.
 Accountable Care Organizations
– Where department get paid for services
 Medical Homes
– Cluster of all health care professional that give care
to a patient. You can treat in multiple settings.
 Annual Wellness Visit
– One time a year can see physician for wellness check
– BP, Medication, Cognitive loss, functional levels,
*need fall risk*
 ‘Incident to’ rules: physician referral hand pick
patients, not apply to therapy cap.
Resources
http://www.cms.gov/
Web page for Centers for Medicare
and Medicaid Services (CMS)
www.ssa.gov/OP_Home/ssact/title
18/1800.htm
– Medicare Act
APTA Government Affairs