HSM Quiz 1
out of pocket costs with skilled nursing facility on medicare part A
$0 for days 1-20 each benefit period $167.50 per day for days 21-100 each benefit period All costs for each day after day 100 in the benefit period
out of pocket costs with home health care on medicare part A
$0 for home health care services 20% of the Medicare-approved amount for durable medical equipment
out of pocket costs for hospice care on medicare part A
$0 for hospice care Copayment of up to $5 per prescription for outpatient prescription drugs 5% of the Medicare-approved amount for inpatient respite care
out of pocket costs with hospital stays on medicare part A
$1,340 deductible and no coinsurance for days 1-60 each benefit period $0 coinsurance for days 1-60 each benefit period $335 per day for days 61-90 each benefit period $670 per "lifetime reserve day" after day 90 each benefit period (up to 60 days over a lifetime) Beneficiary responsible for all costs after 150 days
Medicare Part C - Medicare Advantage Plans
- Medicare beneficiaries who have both Part A and Part B can choose to get their benefits through a variety of risk-based plans ESRD patients cannot enroll unless they have Part C before they get ESRD must live in service area of plan Combines Part A, Part B, and sometimes Part D coverage Managed by private insurance companies approved by Medicare Plans cover medically-necessary services and charge different copayments, coinsurance, or deductibles for these services generally pay the monthly Part B premium and often pay an additional premium directly to their plan Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare Each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services
work conditioning
2 hr of conditioning activities that simulate activities worker will return to
Non-catastrophic injury compensation
2/3 ave weekly wage as long as totally disabled, but not greater than 400 weeks If not working, but capable of working for 52 consecutive or 78 aggregate weeks
Catastrophic injury compensation
2/3 ave weekly wage up to max, also medical and vocational rehab Prevents employee returning to prior work
8 minute rule
8-22 minutes = 1 unit 23-37 minutes = 2 units 38-52 minutes = 3 units 53-67 minutes = 4 units 68-82 minutes = 5 units 83-97 minutes = 6 units 98-112 minutes = 7 units 113-127 minutes = 8 units
general categories of health service questions
Access Cost Quantity Quality Efficiency
Preferred Provider Organizations (PPOs)
An individual, group, or organization that accepts a contract from a MCO to be an approved or preferred provider. differs from a health maintenance plan by offering a choice of providers and through the method of payment. For the increase in patient numbers managers negotiate a discounted FFS rate for services Allows the option of seeking providers out of the panel. These plans have increased premiums and out-of-pocket expenses compared to health maintenance plans, but the enrollee can receive care outside of the panel if needed.
Health Maintenance Organizations (HMOs)
An organization that provides overall health care of a defined population of enrollees under a closed-panel of in-network providers. Closed-panel providers treat only the enrollees of the MCO plan. may have open-panel or out-of-network providers but at an increased cost to the enrollee. The enrollee must see a primary care physician first who acts as a "gatekeeper" to specialty care. Payment to the provider is a fixed amount paid per member per month. PT is available through referral from a primary care physician. Since payment to the provider is capitated (the payment is the same no matter how much or little service is provided), there are provider incentives to treat efficiently and inexpensively.
Posted Panel of Physicians
At least 6 qualified physicians Ortho, minority, 4 qualified MD's Can request 1 change in MD Minority- includes women in GA Workers Comp Managed Care Organization (WC/MCO) Approved by State Board
Conformed Panel
At least ten qualified physicians More than 1 change requires concurrence
Workers Compensation Terms
Average Daily Wage (ADW) Average Weekly Wage (AWW) Independent Medical Exam (IME) Permanent Partial Disability (PPD) Permanent Total Disability (PTD) Temporary Partial Disability (TPD) Temporary Total Disability (TTD) Vocational Rehab (VR) Subsequent Injury Trust Fund Enforcement Unit Subrogation Lien Lawsuit due to injury caused by 3rd party Attorney Charges 25% of income benefits received, plus expenses
Medicare Part A - Covered Services
Blood (starting with the 4th pint of blood in a hospital or SNF during a covered stay) Hospital Stays Skilled Nursing Facility Care Home Health Services Hospice Care
Role of Physical Therapist with workers comp
Care Provider: Immediately provide care Communication Ergonomic Assessment to assist with successful return to work Work Hardening, Work Conditioning More intensive 4-6 hr day where worker simulates activities they will return to 2 hr of conditioning activities that simulate activities worker will return to Functional Capacity Evaluation (FCE) Participate with Impairment Rating Plan spelled out in detail Testing, medications, therapy, surgery, activity modifications, splinting,etc. Length of treatment, recovery, prognosis Documentation very important
General Reimbursement Requirements for workers comp
Charge by CPT code Initial evaluation and re-evaluation (1x each) Exam visits: Only PT and OT's can bill procedures + services Cannot bill for office visit Referral not needed as physical therapist considered a provider* GA workers comp fee schedule states: Under prescription of authorized treating physician detailing the type, frequency, and duration of therapy to be provided
Medicare Part C - Primary Insurance Plans
Coordinated care/Managed care plans, such as Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO) Private, unrestricted fee-for-service plans, which allow beneficiaries to select certain private providers who accept plan's payment Health Savings Account (HSA) - high deductible; Federal government pays into insurance fund & reimburses 100% after deductible; left over money can be used later even for some uncovered services
Medicare - Skilled Maintenance Therapy
Coverage is based on individualized assessment of the patient's condition and the need for skilled care to carry out a safe and effective maintenance program. covered in cases in which needed therapeutic interventions require a high level of complexity.
Compensable injury, illness, or death
Covered by workers comp Performing assigned duties during assigned work hours Injuries incurred during haste or inattentiveness
private health care component
Employers offering health care to employees as a benefit Commercial insurance companies and managed care organizations Individuals who pay for their own health care insurance or pay cash Philanthropists (charity and pro bono care) allows providers to meet health care demands as entrepreneurs who can make a profit and allows consumers to choose where and from whom they obtain services.
Catastrophic Injury
Extremely severe injuries Loss of limbs Severe burns Traumatic brain injury Spinal cord injury Blindness Requires employer to appoint a rehabilitation supplier with expertise in handling catastrophic cases.
who is eligible for medicare
Federal government-sponsored health care program for: People age 65 or older People under age 65 with certain disabilities People any age with end-stage renal disease (ESRD)
Employee Responsibility with workers comp
Follow safety rules Report accident immediately, not later than 30 days Accept Treatment Willful misconduct = no compensation Return to work when able Must attempt job recommended by MD File claims or due benefits within 1 year Drug/alcohol testing required Misdemeanor for false reporting
Medicare Part A-PPS
For Acute Care hospitals the prospective payment system (PPS) uses the patients primary medical diagnosis to categorize them into a diagnostic related group (DRG). PPS in SNF based on resource utilization groups (RUGS); payment based upon skilled services provided by nursing or therapies (PT, OT, SLP). Each DRG is a mutually exclusive grouping used in the case payment rate, which is preset. PROVIDER IS PAID THE CASE RATE REGARDLESS OF THE COST OF PROVIDING THE CARE FOR THE PATIENT. PPS was designed to provide financial incentive to hospitals to control resource utilization and cost. Inpatient rehab, psychiatric, home health, hospice & skilled nursing also paid via PPS
Hospice Care with medicare part A
For people with a terminal illness who are expected to live 6 months or less if the disease runs its normal course. Coverage includes drugs, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare (like grief counseling) for terminal and related conditions. Hospice care is usually given in the home (or other facility where individual may live). Medicare covers some short-term inpatient stays (for pain and symptom management) and inpatient respite care (care given to a hospice patient so that the usual caregiver can rest).
$422
If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is?
Goals of Workers Comp
Immediate and quality medical care Administer claims throughout process Safe return to productive employment
if states do not participate in CHIP Program they must cover these things
Inpatient and outpatient hospital services Physicians' surgical and medical services Laboratory and radiology services Well baby and child care, including immunizations
Subrogation Lien
Lawsuit due to injury caused by 3rd party
Home Health Services with medicare part A
Limited to reasonable and necessary part-time or intermittent skilled care or continuing need for physical therapy, occupational therapy, or speech-related pathology ordered by the doctor and provided by a Medicare-certified home health agency. Home health services may also include medical social services, home health aide services or other services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), and medical supplies for use at home. Home health services include skilled nursing, PT, OT, SLP, home health aide and medical social worker. Patients MUST BE HOMEBOUND to qualify for Home Care under Part A
Hospital Insurance Trust Fund funded primarily by
Mandatory payroll deductions (50/50 employer/employee split) Part A is funded by a tax of 2.9 percent of earnings paid by employers and workers (1.45 percent each). Accounts for 87% of revenue to the Part A Trust Fund in 2015 A portion of income taxes levied on Social Security benefits to high-income beneficiaries Premiums from non-eligible who enroll voluntarily Interests earnings on the trust fund invested assets
Retroactive Eligibility for medicaid
Medicaid coverage may start retroactively for up to 3 months prior to the month of application, if the individual would have been eligible during the retroactive period had he or she applied then. Coverage generally stops at the end of the month in which a person no longer meets the requirements for eligibility.
medicaid prescription drug coverage
Medicaid rules give states the ability to use out of pocket charges to promote the most cost-effective use of prescription drugs. To encourage the use of lower-cost drugs, states may establish different copayments for generic versus brand-name drugs or for drugs included on a preferred drug list.
Employee rights with Workers Comp
Medical, rehab and income benefits Catastrophic vs. non-catastrophic Posted panel of physicians Bills - who pays? Balance billing- when you get a procedure done you pay deductible and co-pay and insurance pays what they will pay and there is money that still needs to be paid that is billed back to pt Co-pay Deductible Weekly Income
Public Health Care Programs
Medicare Medicaid Children's Health Insurance Program (CHIP) Active Military Tricare Veterans Administration Workers Compensation Non-commercial medical research School Health Programs Public Health Clinics Indian Health Service
payroll taxes general revenues beneficiary premiums
Medicare is funded primarily from three sources:
work hardening
More intensive 4-6 hr day where worker simulates activities they will return to
Donut hole with Part D
Most Medicare drug plans have a coverage gap. The coverage gap begins after you and your drug plan together have spent a certain amount for covered drugs. In 2018, once you enter the coverage gap, you pay 35% of the plan's cost for covered brand-name drugs and 44% of the plan's cost for covered generic drugs until you reach the end of the coverage gap. Not everyone will enter the coverage gap because their drug costs won't be high enough. These costs (sometimes called true out-of-pocket, or "TrOOP," costs) all count toward you getting out of the coverage gap: Your yearly deductible, coinsurance, and copayments The discount you get on covered brand-name drugs in the coverage gap What you pay in the coverage gap The drug plan premium and what you pay for drugs that aren't covered don't count toward getting you out of the coverage gap. Some plans offer additional cost sharing reductions in the gap beyond the standard benefits and discounts on brand-name and generic drugs, but they may charge a higher monthly premium. Check with the plan first to see if your drugs would have additional cost-sharing reductions during the gap.
Multiple Concurrent Procedures and Modalities with workers comp
No more than 4 in one visit by each type of provider No more than 2 of the CPT codes can be modality charges Exceptions this include: Catastrophic injury Work Hardening/Conditioning Physical Performance Testing Custom made orthotics/prosthetics By mutual agreement all parties
Not Compensable injury, illness, or death
Not covered by workers comp Unassigned duties Lunch or breaks Normal commute Misconduct claims If fail a drug test after an accident
catastrophic coverage
Once you get out of the coverage gap, you automatically get this you only pay a reduced coinsurance amount or copayment for covered drugs for the rest of the year.
prospective payment system
PPS
parts of medicare
Part A - Hospital Insurance (HI) Part B - Supplementary Medical Insurance (SMI) (also known as physician insurance, medical insurance or the voluntary part of Medicare) Part C - Medicare Advantage Part D - Medicare Prescription Drug Coverage
U.S. Multiparty Payer System
Patient (first party) Provider (second party) Third party payers (third party - payers other than service recipient) Third party payers include private or public forms of insurance.
Medicare Part B - Covered Services
Physician services Outpatient hospital care Clinical laboratory tests Durable medical equipment & most supplies Diagnostic tests and screenings Ambulance services Flu vaccinations Therapy services & other outpatient services Emergency Room Services Some home health services Mental health care (outpatient) Preventative Services
Mandatory Services Include with Medicaid
Physicians' services • Hospital services (inpatient and outpatient) • Laboratory and x-ray services • Early and periodic screening, diagnostic, and treatment (EPSDT) services for individuals under 21 • Federally-qualified health center and rural health clinic services • Family planning services and supplies • Pediatric and family nurse practitioner services • Nurse midwife services • Nursing facility services for individuals 21 and older • Home health care for persons eligible for nursing facility services • Transportation services
return to work program
Project "Stay at Work" - it is the right thing to do Employee Benefit Program Implementation Team Components of Program Timely Reporting Job Activity Analysis Communication Transitional employment Analyze Program Effectiveness
Workers Comp
Protects worker and employer Pays costs associated with employee injury Protects employer from lawsuits Benefits program created by state law Medical, Rehab, and Income provided for a compensable, work related injury, illness or death Goals: Immediate and quality medical care Administer claims throughout process Safe return to productive employment
PT consult goals/objectives with workers comp
Reduce lost days from work Work Injury Prevention Workplace Assessments Ergonomic Assessments Participate with company's safety program Participate with Return to Work Program
Medicare Part D - Medicare Prescription Drug Coverag
Run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered. Two ways to get Medicare prescription drug coverage: 1. Medicare Prescription Drug Plans - These plans (sometimes called "PDPs") add drug coverage to Original Medicare 2. Medicare Advantage Plans (like an HMO or PPO) (sometimes called "MA-PDPs") - These plans provide Part A and Part B coverage, and prescription drug coverage lot of out of pocket costs also have to pay yearly deductible, co-pays, and co-insurance Low-income subsidy (LIS), or "extra help", which helps pay for all or some monthly premium, the annual deductible, and prescription drug co-payments.
hospital stays with medicare part A
Semi-private room, meals, general nursing, and other hospital services and supplies. This includes inpatient care received in acute care hospitals, critical access hospitals, inpatient care as part of a clinical research study and mental health care. This does not include private-duty nursing or a television or telephone in the room. It also does not include a private room, unless medically necessary. Inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime.
Skilled Nursing Facility Care with medicare part A
Semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies (only after a 3-day minimum inpatient hospital stay for a related illness or injury) for up to 100 days in a benefit period. To get care in a skilled nursing facility, the individual must need skilled care like intravenous injections or physical therapy. Medicare does not cover long-term care or custodial care in this setting.
Medicare Part A coverage of Physical Therapy must meet 4 conditions:
Services are provided to an inpatient of a participating hospital; Services are provided to an inpatient of a participating skilled nursing facility; the patient's stay must be eligible for Part A coverage under Medicare; Services are provided by a participating home health agency to a patient following a hospital or skilled nursing inpatient stay; Services are provided by a participating hospice.
Coverage Guidelines Include
Services covered, partially covered and excluded from coverage; Coverage limits by amount, type or source of service; Source of care, care giver qualifications, provider type, authorized service locations; Service preauthorization requirements; Service and charge documentation requirements, including required forms and submission requirements; Directions for obtaining preauthorization for covered services; Procedures for addressing any disputed preauthorization decision of the payer; Responsibilities of patients, providers, and insurer if non-covered, non-authorized services provided Payment limits discounts and incentives that apply to the enrollee or payer; Bill processing procedures and contacts; Administrative responsibilities of the subscriber, provider and sometimes the payer.
dual eligibles
Some people qualify for both Medicare and Medicaid. These people
Non-emergency Use of the Emergency Department for medicaid
States have the option to impose higher copayments when people visit a hospital emergency department for non-emergency services. This copayment is limited to non-emergency services, as emergency services are exempted from all out of pocket charges
Medicaid - Payments
States may pay providers directly States may pay through prepayment (e.g., HMO) In provider surveys and other research, low provider payment and paperwork burdens consistently emerge as the leading barriers to provider acceptance of Medicaid (leads to shortage or providers and limited access to care) States may pay providers directly States may pay through prepayment (e.g., HMO) In provider surveys and other research, low provider payment and paperwork burdens consistently emerge as the leading barriers to provider acceptance of Medicaid (leads to shortage or providers and limited access to care) a lot of cost sharing with federal gov and state
medicare reimbursement with students
Students do not meet the definition of practitioner in section 1861 of statute Services performed by students will not be paid under the Medicare Part B program Student minutes are counted under Part A Students can treat Medicare patients, but services cannot be billed
Consumer-Directed Health Care (CDHC)
The combination of a high-deductible health insurance plan (HDHP) with a tax-preferred savings account used to pay for routine health care expenses individuals must have a high deductible health plan. You as individual have more choice in what you spend money on for health care needs Plan is high deductible plan and tied in with health reimbursement account of Health Saving Accounts (HSA)- health saving account Lower premium, higher deductible and have HSA attached to it , individuals with an HSA pay for routine health care expenses out of their savings account. After the accounts are depleted, individuals pay directly out-of-pocket until they have reached the relatively high deductible amount in their health plan. Because the plan has a high deductible, monthly premiums are often lower than traditional health insurance. Consumers may keep any unspent dollars in their account, creating an additional incentive to be cost-conscious when purchasing their health services. Employers or individuals can contribute to the HSAs. All money put into an HSA is pre-tax. (You don't pay taxes on it.) Any money deposited into a HSA is considered an "above-the-line" deduction with a 100% write-off against adjusted gross income. Earnings on the money in your HSA are tax-free. (Interest and any capital gains on investments accumulates tax deferred until age 65. At this point individuals have the opportunity to continue to use accumulated savings for medical expenses tax free, or withdraw them for non-qualified expenses at normal tax rates.) Withdrawals for qualified medical expenses are tax-free Other tax-favored health plans: Medical Savings Accounts (MSAs) Flexible Spending Arrangements (FSAs) Health Reimbursement Arrangements (HRAs)
Tax-Funded Health Care
The federal government is a third-party payer. Allocates funds to cover health care for several federal departments, along with targeted segments of the population. Major federal entities are: Department of Defense (DOD) Department of Veterans Affairs Department of Justice (DOJ) Office of Personnel Management Department of Health and Human Services (HHS) Also state and local government programs.
Medicare A
Usually do not pay a monthly premium for coverage if 65 or older and individual or spouse paid Medicare taxes while working ; or if 65 or older and already receive SS benefits; or under 65 and SS Disability for 24 mos., ALS or ESRD. If not eligible for premium-free , may be able to purchase it if individual meets one of these conditions: Did not work or did not pay enough Medicare taxes while working and is age 65 or older Disabled and has returned to work If you paid Medicare taxes for less than 30 quarters, the standard premium is $422. If purchased, must also have or enroll in Part B and pay the monthly Part B premium. Administered through the Centers for Medicare and Medicaid (CMS) Medicare Trust Fund
Weekly Income with Worker's Comp
Weekly income is > 7 lost work days If out greater than 21 days - get 1st week paid If return to work for less pay, get weekly benefit not > 350 weeks If working as PT in acute care and cannot return to job but go to job where you are getting paid less- worker's comp will pay difference in pay Insurance company penalized $$ if benefits not paid when due' In GA had to be within 30 days
Coinsurance
a portion of cost paid by the individual after the deductible is met (i.e. 80% paid by the insurance company, 20% paid by the individual)
Conditions of Participation (CoPs) and Conditions for Coverage (CfCs)
developed by CMS conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. apply to: Home Health Agencies Hospices Hospitals Providers of Outpatient Services (physical and occupational therapists in independent practice; outpatient physical therapy, occupational therapy, and speech pathology services) Skilled Nursing Facilities
public health care component
includes Medicare and Medicaid programs that evolved to care for the poor, disabled, and other needy segments of society. Funded by payroll taxes and federal and state general revenues This social philosophy reflects the recognition of responsibility of the greater community to ensure access to health care for those least able to meet this need on their own. Medicare is funded by taxes Medicaid is more state funded These are attempts to make sure older and low income people are able to receive health care services
Children's Health Insurance Program (CHIP)
jointly financed by the Federal and State governments and is administered by the States. Designed to help states expand coverage to uninsured children. Provides health coverage to nearly eight million children in families with incomes too high to qualify for Medicaid, but can't afford private coverage. For individuals 18 and under Gap between what medicaid will cover vs private insurance This helps people who cannot afford insurance but do not qualify medicaid For individuals 18 and under Gap between what medicaid will cover vs private insurance This helps people who cannot afford insurance but do not qualify medicaid
Insurance Coverage Guidelines
legal requirements that beneficiaries and participating providers are required to follow. Specify administrative requirements that must be met before payment is made. Specify which health care services are and are not covered by the plan vary greatly between payers, geographical regions, and over time
Medicare Part B - Beneficiary Out-of-Pocket Costs
monthly premium yearly deductible beneficiary to pay co-insurance In most cases the beneficiary pays 20% of the Medicare-approved amount for the service based on income has therapy caps If the patient has already met the Medicare deductible: Medicare pays 80% Beneficiary pays 20% If the patient has already met the Medicare deductible: Medicare pays 80% Beneficiary pays 20%
main components of US health care system
privately funded - based on a capitalistic philosophy with a free-market economy and competition publicly or tax supported - based on a social philosophy that the government has the responsibility to provide access to health care, especially to those in need most responsive, superb in development of medical technology (increases cost), techniques (increases cost), and new drugs (increases costs), has sufficient and well-educated work force, and sufficient facilities
Health Care Claims processing
procedure costs $100 pt pays co-pay of $10 claim goes to clearing house for $90 reimbursement clearing house decides where it needs to go Then where it is sent decides what to do with it and determines if it was worth $90 If not worth that then is repriced provider decides procedure was only worth $60 $90 Claim is 'processed' and the provider is ultimately paid $30 Total Reimbursement for $100 charge is $40 ($10 co-pay + $30)
Medicaid - Eligibility
provide health coverage to nearly 60 million Americans, including children, pregnant women, parents, seniors and individuals with disabilities. federal law requires states to cover certain population groups (mandatory eligibility groups) and gives them the flexibility to cover other population groups (optional eligibility groups). States set individual eligibility criteria within federal minimum standards. States can apply to CMS for a waiver of federal law to expand health coverage beyond these groups. Individuals who meet standard of low-income families with children--Aid to Families with Dependent Children (AFDC) Children <6 whose family income <133% of poverty level Pregnant women with family income <133% of poverty level (services limited to those related to pregnancy, complications of pregnancy, delivery, and postpartum care) SSI recipients in most states Recipients of adoption or foster care assistance Specially protected groups (typically individuals who lose cash assistance due to earnings from work or from increased SS benefits, but who may keep Medicaid for a period of time) Children <19 in families with incomes less than poverty level States have the option of providing coverage for other "categorically related" groups. These optional groups share characteristics of the mandatory groups but the eligibility criteria are more liberally defined. state cannot limit enrollment in the program or establish a waiting list.
Co-payment
the amount the individual must pay each time services are received or prescription drugs are purchased
deductible
the amount the individual must pay each year before the health care plan begins to pay
self-insure
the employer collects premiums and uses the pool of funds to pay health care expenses
medicaid
the nation's publicly financed health and long-term care coverage program for low-income people. Enacted in 1965 under Title XIX of the Social Security Act federal entitlement program that was initially established to provide medical assistance to individuals and families receiving cash assistance, or "welfare." financed jointly by the federal government and the states. The federal government matches state spending States are entitled to these federal matching dollars, and there is no funding cap, which allows federal funds to flow to states based on actual need. Through the matching system, the federal government and the states share the cost of the program Federal law outlines basic minimum requirements that all state programs must fulfill. States have broad authority to define eligibility, benefits, provider payment, and other aspects of their programs administered by state
entrepreneurial
type of US health care system
Indemnity Insurance Plans
type of commercial insurance plan Few exclusions or limitations. Cover costs of care of insured up to the dollar amount set by the policy. Choice of providers and payments to providers is unrestricted. Most costly to the insured since it is potentially the most costly to the insurance company. Most of services are provided by anyone you choose to go to You pay for it - premiums are high The method of payment is called fee for service (FFS). The provider can charge a fee for each individual service. The amount paid to the provider is based on a "usual and customary rate". Some providers accept this as full payment; in other cases the insured is responsible for the difference charge for each service individually FFS is the most common type of payment methodology for outpatient PT services Each service has a distinct code that is reported on either the CMS-1500 paper claim form or on the electronic 837P form.
Managed Care Insurance Plan (MCO)
type of commercial insurance plan created with restrictions and limitations intended to decrease and control health care costs. A majority of U.S. citizens are enrolled Ones that are most restricted and have least amount of choice- lower premium don't have to pay as much out of pocket business entity that is a health care provider, insurer, or both arranges and pays for delivery of care through its own providers, contractual arrangements with individual groups or organizations, or through both. Arrangements with selected providers to furnish a comprehensive set of health care services to members; Explicit standards for health care providers; Formal programs for ongoing quality assurance and utilization review; Significant financial incentives for members to use providers and procedures associated with plan; Financial incentives for plans &/or providers to limit unnecessary or questionable procedures require some out of pocket costs: deductible. coinsurance, co-pay types: HMO, PPO. POS
Medicare Part B - Medical Insurance
voluntary program need it if you pay for Part A Helps cover medically-necessary services like doctors' services, outpatient care, and other medical services not covered by Part A including some preventive servicesAdministered through CMS Financed: 75% by general federal revenues 25% by beneficiary premiums Higher income beneficiaries pay a larger share of spending
if have 3 or more emoloyees
workers comp is required when