OT722 Quiz 2

Preferred Provider Organization (PPO)

-Consumers are required to choose from specific list of providers -Going with provider outside the list has additional consumer costs -Example of limiting competition in the health care market

Mission

- Statement should be clear, specific, measurable, and capable of being both understood and embraced by everyone responsible for achieving the ________

Full time equivalent (FTE)

-8 hrs per work day -5 days a wk -~40 hrs per wk -52 weeks per yr -~2,080 hrs per yr = 1 ___ OR 0.5 ___ = ~1,040 hrs per yr

Not so free market system

-Access to healthcare services -Availability of healthcare services -Payment of services involved 3rd parties -Managed care "Access, Availability, Payment & Manage"

Legislation & Healthcare Policy

-Brings changes to healthcare policies at both the federal & state levels -Multiple healthcare programs which received fed funding from the fed level -Changes in healthcare policies can fundamentally impact funding for healthcare programs which then has the ripple effect of impacting payment for OT services

Medicare part "B"

Covers: -Doc & other healthcare services -Outpt care -Home healthcare -DME -Preventive services

Medicare part "A"

Covers: -Inpt care in hospitals -SNF care -Hospice care -Home health care

Free market system key principles

1. Supply & demand 2. Competition 3. Free choice

Importance of documentation

"The primary and obvious purpose of the health record is to document a client's health info for future reference"

Medicare

-Fed funded and largest payer of health care services -65+ y/o -Eligible to sign up 3 months prior to turning 65 y/o -Specific dx may apply for people under 64 y/o -Made up of 4 parts ("A", "B", "C", & "D")

Values

-Foundational principles of one's business -Tells you what a business stands for and will not stand for -Gives guidance/direction in decision making and everything you do in a business

Health Maintenance Organization (HMO)

-General practitioner must be seen before seeing specialist -Specialist referral is in network -Example of limiting competition in the health care market

US #s for Civilian Employees

-Hourly pay = $26.85 -Total benefits = $12.06 -Total compensation = $38.91 per hr -Benefits packages are around 31% of overall compensation

Documentation types

-Initial eval -Progress notes -Discharge summary

Compensation (personal budget)

-Insurance = 8% -SS, Medicare = 7.7% (by law) -Vacation = 7% -Supplemental pay = 2.5%

ACA value-based services

-Intended to deliver high quality services defined as improved outcomes using defined quality measures at a lower cost -ACA initiated the incentivizationof good outcomes and quality of care along with penalization of poor outcomes and quality Hospital Readmission Reduction Program (HRRP) Potentially Preventable Readmission Measure (PPR)

Medicaid

-Jointly funded by fed gov & individual states -Each state determines eligibility and payment but must at least meet minimum standards set by the fed gov -Payment rate is on the lower end of the scale -Providers health insurance for individuals and families with low income -Includes individuals with long-term disabilities who have less than a 10 year work history -Almost 1/2 of Medicaid consumers are children

Medicaid GA

-Medical assistance program that helps low income individuals & families -Administered by the GA dept of community health (GA DCH) -Funding is provided by contributions from both fed gov and state of GA

Personal budget

-More than salaries -Includes health insurance, retirement, liability insurance, vacation, etc -Benefits packages

Katie Beckett Medicaid (KB)

-Provides benefits to certain children 18 y/o or younger who qualify as disabled individuals and who live at home rather than in an institution -Qualification not based on income -Qualification is based on institutional level of care the child requires

Medicare part "D"

-Run by private practice insurances who must meet Medicare standards -Assists in covering the cost of prescription drugs -Typically obtained in addition to regular Medicare PRESCRIPTION DRUGS

Purposes of documentation

-Sources of communication for the health care team -Source for evidence for billing & reimbursement -makes a case for justifying or denying services -Legal record of client care -Mechanism for quality management -Utilized to support accreditation requirements -Potentially used for education and research -Business growth & development

Organizational chart

-Visual depiction of the structure of a business or organization -Provides info on the organizational structure of positions &/or departments along with illustrating the hierarchical relationships between positions &/or departments

Vision

-What one's business would look like if it were "perfect" -Expresses an aspirational message about what an organization would like to become as it seeks to fulfill its mission

3 CMOs for Medicaid in GA

1. Amerigroup Community Care 2. Care Source 3. Peach State Health Plan

The 4 primary goals of ACA

1. Create affordable health insurance marketplaces and plans in each state 2. Regulate insurance plans in order to provide coverage for underserved or previous "uninsurable" groups (pre-existing conditions) 3. Expand Medicaid to additional populations (EX: low income adults with no children) 4. Create programs and payment models with focus on lover costs and better outcomes

4 Requirements of budget knowledge

1. Healthcare systems are at the local, state, and federal level 2. Payor sources (insurances), reimbursement structures 3. Human resources and associated costs 4. Materials and equipment 5. Facilities management

Why? Who? How?

A mission statement should address 3 things....what are they?

Medigap

Additional insurance one can buy from a private company that helps pay regular Medicare bills -Policies are standardized in that benefits are the same across all the private insurance companies offering this coverage

Example of medicare advantage

Being d/c to a SNF instead of an inpt rehabilitation

Operating expenses budget

Costs associated with everyday running of the business -includes building rent, utilities, office supplies, etc

Medicare part "C"

Covers: -Services similar to parts "A" &"B" but provided under the umbrella of private companies/insurances -Typically are limited to healthcare providers in network -Some plans include additional benefits (vision, hearing, dentist, etc) which are not typically covered under regular Medicare KNOWN AS MEDICARE ADVANTAGE

Patient Protection & Affordable Healthcare Act (ACA)

Created to address the "triple aim of healthcare" 1. Improves population health outcomes 2. Improves healthcare consumer satisfaction 3. Reduce costs

Job description

Creating a ___ __________ allows you to shape what you consider best practice -Provides a tool to "create the world you want to work in" -Help with navigating legal situations -Provide measures & benchmarks for performance evals -Assists with addressing discipline process

Care Management Organization (CMO)

Entity that is organized for the purpose of providing or arranging healthcare which has been granted a certificate of authority by the commissioner of insurances as a health maintenance organization -Has entered into a contract with the department of community health to provide or arrange healthcare services on a prepaid, capitated basis to members

Accreditation

Process by which an authorized 3rd party will review the operations of a business to ensure that business is operating in a manner that is consistent with set standards Benefits of ___________ include: -meets requirements of funding sources such as 3rd party payors -viewed as a commitment to quality -brings recognition from consumers Examples of ________ include: -CARF -TJC -AAAASF

When creating documentation templates....

Think of: -Populations you serve -Health conditions and related assessment needs -Utilizing assessments supported by evidence -Utilizing output info that supports justification of your services -Measureable progress DO EVERYTHING IN YOUR POWER TO JUSTIFY SERVICES

Medicare advantage

Type of Medicare that impacts discharge planning -Mandates where a pt goes after d/c -Meet minimum standard defined -Control as to how services are covered

Capital equipment

Typically individual items priced over $500 and durability of greater than 1 year - "large expenses" you will need for a business

Planning & Controlling

What are the 2 functions of budgeting?

Planning

What is the costs or financial impact of meeting the needs of your clients or consumers?

Controlling

What limits do you need to set to keep from overspending?

Start up expenses

_________ expense include but are not limited to.... -Physical space (rent vs buy vs build) -Office equipment & supplies -Therapy equipment & supplies -Phone & internet -Utilities -Business license & permits -Building & liability insurance -Salaries -Materials for marketing -Website development -Documentation system