ACMA Case Management Certifican study help

What is the "Important Message from Medicare" handout?

Notice that is given to in patient medicare beneficiaries that informs them of their righr to appeal a hospital discharge

5 rights of utilization and review

1. Provider 2. Services 3. Setting 4. Time 5. Cost

How is value based pricing scored?

2 scores- Performance compared to other hospitals, improvement in their own performance

Physician certification or recertification for admissions longer than ____ days requires what documentation?

20 days. Reason for hoslitalization estimated length of continued stay, post acute plans, if patient is only waiting on SNF placement must indicate reason for delay.

What are the three steps to integrated CM?

3 functions of ----1. Track patient self management2. Tend/track population management3. Reporting, monitoring quality

What percentage does Medicare Part B cover?

80% of covered services

When is HINN 10 given?

AKA the Notice of Hospital Required Review (HRR) should be issued by hospitals when ever a hospital requests QIO review of a discharge decision without physician concurrence. HINN may be used for original Medicare or Medicare advantage enrollees.

uniform healthcare decisions act (UHCDA)

Addresses who can make medical decisions if patient is incapacitated and lacks advance directive. 1. Spouse 2. Adult child 3. Parent 4. Adult sibling. if no family - court appointed guardian

What is an example of assessing for health literacy?

Asking patient to teach back what has been taught

Components of RED ( Reengineered discharge)

Asses need for translator, sched f/u appointments, f/u on outstanding test results, coordinate post d/c out-patient services, obtaining medications national d/c guidelines, d/c teaching, educate on what to do if problems arise, assess pt understanding, d/c summary to outside providers, d/c follow up call. After Hospital Care Plan (AHCP)

Population Specific Assessment Considerations - Workers Comp

Asses what Pt can and cannot do in their essential job functions and an occupational history.

4 stages of case management

Assess, plan, implement/intervention, monitor/evaluation

What is InterQual?

Clinical decision support tool determines when and how a patient progresses through the continuum.- organizes resources utilization,- objective evidence based criteria for assessing appropriate care for patients. Helps fraud/abuae

Patient Goals

Clinical treatment and diagnosis, Comfort and Supportive Care, Restorative/rehabilitative care, Discharge or transitional planning.

what are Conditions of Coverage and Conditions of Participation?

Conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. These health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries.

What did the HITECH portion of the American Recovery and Reinvestnent Act of 2009 promote in regards to Healthcare?

Conversion of paper based charting to computer based systems.

What is the Detailed Notice of Discharge?

DND explains specific reasons for DC, Given only if Pt appeals d/c

How are DRG payments determined?

DRGs categorize patients with respect to diagnosis, treatment and length of hospital stay. The assignment of a DRG depends on the following variables: Principal diagnosis Secondary diagnosis(es) Surgical procedures performed Comorbidities and complications Patient's age and sex Discharge status

Population Specific Assessment Considertions - Newly Hospitalized patients

Determine appropriate level of care. Tool often used - MCG, InterQual (McKesson), Centers for Medicare & Medicaid Services National Coverage Database

keys to effective d/c planning

Elicit patient choice (SNF etc.) Communication w/team regarding timing, and plan for d/c. Communication with outside services/vendors Communication w/family regarding patients status, needs and next k even of care. Communication w/ health plan regarding plan of care, medications etc. Confirm outside services, medications, transportation etc are approved and ready. Secure needed orders, prescriptions, orders etc from medical team to assure timely discharge.

What are the goals of CM

Ensure patients receive quality cost-effective, safe, high quality, evidence-based care in the least restrictive setting

Required assessment for admission to a nursing home for a patient with a diagnosis of mental retardation

Federal Pre-Admission Screening and Resident Review. Some states may require additional screen in ng tools.

What is the required assessment for admission to a nursing home for a patient with a diagnosis of mental retardation or mental illness to assure appropriate placement

Federal Pre-Admission Screening and Resident Review. Some states may require additional screening tools.

How do you qualify for Medicaid?

Financial requirements and those determined by each state and must be a citizen or an immigrant with 5 years legal residency. Based on income and financial resources.If you've already been receiving government Social SecurityIf a child less than 21 years old and has a disability severe enough to meet disability standards under Social Security disability. Parental income is disregarded

What is a condition code 44?

For Medicare services, when a UM review team has determined that an order for inpatient admission is not medically necessary. Order can be changed to observation. The admission will be billed under part B Medicare only

Common risk stratification models

Hierarchical condition categories (icd-10), Adjusted clinic groups (Johns Hopkins) projects use of medical resources), Chronic Comorbidity counts (AHRQ) 6 categories), Elder Risk Assesment (risk for hospitalization and ED visits), Charlton Comorbidity Measure (predicts risk of 1 yearmortality based in diagnosis), Minnesota Tiering (tiers patients on complexity of major conditions)

Other Assessment details that are helpful

Home support, physical and environmental barriers, occupation, educational level, accessibility to resources, experience with Healthcare, previous accidents, learning barriers, language barriers, Pt goals experiences of care, fearfrustrations etc.

Medicare Part A covers

Hospital Skilled nursing facilities Hospice Approved Home Health

What does the acronym IDEAL stand for?

INCLUDE the patient and family as full partners in the discharge planning process. DISCUSS with the patient and family key areas to prevent problems at home. EDUCATE the patient and family in plain language about the patients condition, the discharge process and next steps at every opportunity throughout the hospital stay. ASSESS how well doctors and nurses explain the diagnosis, condition, and next steps in the patients care to the patient and family. Use teach back. LISTEN to and honor the patient and family's goals preferences, observations, and concerns.

Population Specific Assessment Considerations - ED

Identify high ED services users and developers plans to when patients present to ED with same symptoms as previous visits. Pts are often asked to sign them

Is there a premium for Medicare part A?

No if you qualify, But there are deductibles for 2020 the deductible was approximately $1400 each episodes

Is long term care covered by medicare?

No. Medicaid pays for it if Pt qualifies (income limits), or long term care insurance.

What roles constitute integrated CM?

Includes well being, disease management, case management, prevention, triage, utilization management

When should medication reconciliation be done?

It should be done at each stage of health care delivery: - Admission - Status - Patient transfer within or between facilities/provider teams - Discharge

What does the Acronym LACE stand for in the Lace Assesment tool..

LENGTH of Stay, ACUITY of Admission, COMORBIDITY, EMERGENCY Deoartment Visits.

What does the acronym LEAN stand for

Leadership, Eliminate waste, Act now, Never ending

CMS guidelines for Home Health Services

MD must certify the treatment is necessary and he has personally examined patient. the patient must be homebound (supporting docs required)

What part of Medicare covers admission to SNF?

Medicare Part A covers care in a skilled nursing facility (SNF) for up to 100 days during each spell of illness. If coverage criteria are met, the patient is entitled to full payment for the first 20 days of care. From the 21st through the 100th day, the patient is responsible for a daily co-insurance amount which generally increases each year.

Which Medicare pays for hospice services?

Medicare part A covers medical supplies equipment medications nurses doctors dietitians used

What are the medicare guidelines regarding SNF admission?

Must be inpatient status for three consecutive days. if not Pt will need to pay out of pocket. Does not include day of discharge, ED, or observation.

How can decision of competence be determined?

Only by a court of law.

What part of Medicare covers skilled nursing facility?

Part A

Is there a coverage premium for Medicare?

Part A no, unless you have not worked long enough. There is a deductible for each occurrence. Part B - yes + annual deductible + 20% copay for services. Part C - Medicare Advantage has all parts - premiums through private insurer Part D - Covers drug. Must buy through private insurer. Usually has deductible, co-pays (5-25%) and types of out of pocket maximums where copays decrease.

What part of Medicare covers DME equipment?

Part B

What are the key elements of CM planning?

Patient engagement, dynamic process (ability to change plan as needed), patient centered, collaborative (team), fiscally responsible.

What does Medicare part B cover?

Physicians Services Outpatient hospital services Medical equipment and supplies Diagnostic screenings ambulance transportation

Pre-admossion patient assessment includes

Pre-admossion engagement, identification of caregiver, advanced directives, discharge needs, discharge barriers. setting expectation for d/c, including selfcare abilities and expectations, assessment of home environment, potential risk factors for readmission, support system.

When is a patient liable for services delivered after an HINN is submitted?

Preadmission - all services except those eligible under part B Admission - if admission notice is issued at 3:00 pm or earlier, the patient is liable for services delivered after the notice is given, except services that are eligible under part B. if issued after 3:00 liability begins the next day.

what are the time frames to submit an appeal for QIO review?

Preadmission- No later then three calendar days after receiot. Admission - ASAP for immediate review

When does care coordination begin and end

Prior to admission for elective procedure - 30-90 days after discharge.

When is HINN 1 given

Prior to admission to an entirely noncovered hospital stay.

What are the 8 ps in The Society for Hospital Medicines Project Boost Risk Assesment - Readmission Assement

Problems with Medications, Psychological, Principal Diagnosis, Physical Limitations, Poor Health Literacy, Patient Support, Prior Hospitalization, Palliative Care

What is QIO the abbreviation for?

Quality Improvement Oganizations which work to improve care to medicare bebficiaries. Beneficiary and Family Centered Care QIO help beneficiaries exercise their right for high quality care by managing complaints and appeals..

What is decision making capacity?

The ability to make decisions. Ability may vary from situation to situation. . It is different from competency which is only determined by court of law.

What requirements must be met to bill a Condition Code 44?

The change must be made prior to discharge. The claim has not been submitted, The MD concurs with the UM decision, occurrence is documented in the medical record.

What is the patient self determination act (1990)

The right for patients to refuse care/right to die. Facilities participating in Medicare/Medicaid must inform patients of these rights. Advanced directives and Durable POA for healthcare

What are social determinants of health?

The structural determinants and conditions in which people are born, grow, live, work, and age which have a significant impact on health outcomes.

Which immigration status is eligible to purchase coverage through the Heakth Insurance Marketplace?

U.S. Citizens, U.S. Nationals, Lawfully present immigrants. - illegal immigrants cannot purchase it for themselves but may apply on behalf of documented individuals.

Pay for performance models have a greater emphasis on

Value based purchasing, readmission, Hospital acquired conditions

In regards to Value Based Pricing/payments, what factors are used to determine payout for safety?

Various patient safety factors and infection rates

Medication reconciliation

Very important to send upon transfer to reduce risk of readmission

When is HINN 11 given?

When non covered items or services are provided during an otherwise covered stay.

Things to consider when a patient is in Observation

Will patient be safe and clinically ready to discharge home in 24 hours? is patient likely to need inpatient admission? Can the patient be care for in an alternative setting such as SNF, hospice, home w/ HH? can tests, procedures and consults being ordered be expedited or better coordinated to limit length of stay?

What are the guidelines to qualify for Medicare Part A

You must have worked a certain number of "quarters of coverage to qualify. If you are a U.S. citizen or permanent resident and have not worked long enough to qualify for Medicare, you may able to buy into the program by paying a Part A premium. You may qualify if you apply under a spouse.

What is the IMPACT act?

a 2014 act that requires submission of standardized data by long term care hospitals, SNF, home health agencies, and rehab facilities. improving Medicare post acute care transformation act

What is the emergency medical treatment and active labor act (EMTALA)?

a law in 1986 that requires hospital receiving medicare and have an ER to asses, provide treatment and stabilize a patient before determining their ability to pay. An amendment in 1989 requires hospitals to accept transfer of a patient requiring special treatment regardless of ability to pay.

FMLA

a law that requires employers (50 or more employees) to provide up to 12 weeks of unpaid job-protected leave in a 12 month period for employees who have worked for at least 1 year for a certain family or medical reason.They may also work fewer hours a week or work day if medical condition warrants. This must be granted for births, adoption, foster care, family is sick, to attend to a serious health condition. Doesn't protect your particular job.

What is palliative care

a type of care for someone with a serious illness and needs help with symptom management they do not have to be terminally ill and there is no time limit. May be covered under Medicare Part B

HIPAA individual right #3 is the individual's right to their health information to do what?

access, inspect, copy

Population Specific Assessment Considrrations - D/C planning

all equipment, medications, and supports for safe dc to lower risk for readmission. Authorization of insurance etc.

what is a physician advisor?

an MD with broad clinixal experience who acts a a liason between hospital staff to ensure compliance with regulatory issues, medical necessity, length of stay, denials,, icd-10 codes, peer review, and utilization of Healthcare services.

Population Specific Assessment Considerations - D/C from acute care Elderly

cognitive abilities, ADLs (selfcare), physical limitations, ADLs functional ie banking, cooking etc.

What is six sigma

data driven quality management process to eliminate defects: define, measure, analyze, improve/design, control/verify

What factors effect social determinents of health?

economic stability, neighborhood and built environment, education, food, community and social context, health and health care.

More social determinents of health

employment/work conditions, education and literacy, childhood experiences, social support and social skills, access to health services, gender, biology and genetics, healthy behaviors, social environment, physical environment, income social status

What are the components of a psychosocial history

family composition, education, occupation, psychological and/or psychiatric functioning, living siuation, support system, transportation concerns, life changes or stressor, cooing skills, social/ community involvement, spiritual aspects and concerns, self care, cognitive or perception problems, financial concerns.

components of the psychosocial history

family composition, education, occupation, psychological and/or psychiatric functioning, living siuation, support system, transportation concerns, life changes or stressor, cooing skills, social/ community involvement, spiritual aspects and concerns, self care, cognitive or perception problems, financial concerns.

What doesHINN stand for?

hospital issued notice of non-coverage - It is given to patients when items or services are not covered because it is Not medically necessary. Not delivered in the most appropriate setting or custodial in nature.

What are the requirements for delivery of HINN notices?

in person delivery, Notice delivery to Representatives, e7o

office of inspector General

investigates medicare and medicaid fraud.

When is HINN 12 given?

it is given along with the Hospital Discharge Appeal Notices to inform beneficiaries of their potential financial liability for non covered continued stay.

What is Medicare part C

medicare part C + choice program, also knows as the medicare advantage plan, is a managed care option that allows new types of health plans under private companies to cover medicare benefits at a capitated (per enrollee) amount to include hospital and medical, parts A and B.

examples of skilled homehealth needs

monitoring of new meds medication teaching pulmonary assessments wound care ostomy care diabetic care and insulin teaching PT infusion therapy respiratory care during these services Pt may eligibke to have other services such HH aid, SW

In regards to Value Based Pricing/payments, What factors weigh heavily in clinical care outcomes?

mortality

post discharge follow up includes

prescriptions filled, medications, diet, activity/limitations regime understood. Follow-up or testing appt made transportation arranged Homecare or other services initiated

Diagnostic related group (DRG)

pricing formula used by medicare that reimburses a fixed amount based on a diagnosis. Utilization review department case managers evaluate if a diagnostic test is medically necessary.

When must the HINN be given?

prior to admission, or any point during an in patient stay if it is determined that the items or services are not covered because it is not medically necessary. not delivered in the most appropriate setting or custodial in nature.

Peer Review Quality Improvement Organization (QIO)

private not for profit organization contracted by the center for medicare and medicaid services consisting of health care professionals who review complaints about care and implement changes for medicare patients. They ensure the patient right care for the right person at the right time is safe, patient centered, timely, and equitable. Part of the US department of health and human services.

What factors effect value based purchasing?

quality of care,, reduce adverse events/safety, improving patient experience, efficiency/delivering low cost care.

What is utilization and review?

reviewing patients clinical condition and providing decis I on support to MD on bed and billing status. ie observation, Out Pt, In-Patient. and being prepared to justify medical necessity. Additional certification is required for admission Ions longer than 20 days.

What assessments are required to be reported under the IMPACT act of 2014

skin integrity, functional status, medication reconciliation, falls, forwarding of HIM upon transfer, estimated spending per beneficiary, dc to community, preventable readmission.

In regards to Value Based Pricing/payments, what factors are used to determine payout based on efficiency.

spending per beneficiary, 3 days prior to admission to 30 days post d/c. Resource utilization, length of stay, post acute services.

In regards to Value Based Pricing/payments, what factors are considered in Patient experience of Care

staff communication, receiving written d/c information, warning signs, explanation of medications, pain management, overall experience.

what happen if a QIO appeal is lost?

the QIO will determine the date at which the patient is responsible k e for the charges. If patient is still admitted the patient may request a redetermination

What is the definition of health literacy ?

the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.

What is a QIO Review?

the initial step for an appeal to a denial of coverage Including admittance to a hospital or discharge to HH, SNF, rehab or hospice.

Prospective Pay

type of payment that changed medicare reimbursement from a fee for service to a fixed payment based on DRG (diagnostic related group)_.

capitation

type of payment to a provider for a group of people assigned to them where there is a fixed cost per person, per time period , not dependent on how often that person utilizes the resources. The provider is contracted under a HMO.per member, per mont