- the interim step in dev universal health insurance

- legislative attempts began in 1957

- Lynda Johnson elected & proponents of public health insurance are strong in congress & executive branch in 1964

- Medicare passed in July 1965 & signed into law

1. Part A: provided coverage for inpatient hospital stays, short term rehab

2. Part B: supplemental med insurance, professional services (OT)

3. Medicaid: extension to provide care to the poot

- changes made in PPACA

- $513 billion on health care for 48.6 million beneficiaries

*Most money spent on Medicare Part A (hospitals/SNFs)

- 2 programs: Original Medicare & Medicare Advantage

*Medicare Advantage: enacted by congress in 2003 as redesign of the 1997 Medicare Part C program

*Medicare Part D (prescription drug benefit): stand alone or included in Medicare advantage

-Cost concerns have ^:

*1st year: < 2 billion was funded by 0.35% payroll tax on first $6,000 of a worker's earnings

*Today 2.9% (1.45% from employee & 1.45% from employer) tax on all earnings

> Rest paid through premiums & coinsurance

- Federal Entitlement program:

*eligible persons are guaranteed a set of benefits as defined by law

- Social insurance (worker's pay taxes to pay for healthcare of those disabled or elderly)

- Medicare policy is established by congressional legislation

Medicare procedures:

- Dev & implemented by the Center for Medicare & Medicaid Services (CMS)

- Part of the dpt of Health & Human Services

- Claims review & eligibility is processed by private organizations

*usually done by insurance companies

- Med A & Med B reviewed y Medicare Administrative Contractors (MACs)

* Appropriateness/eligibility of therapy services

- A/B Jurisdiction Map (12) separated by certain regions/states

- Prospective payment system (PPS)= case-based

- benefits based on payroll/premium contributions, age, marital status, or the presence of permanent disbaility

- most qualify based o age (65) and a record of contributions for 40 quarters (10 years)

- if not vested, may access Medicare after 65 and agreeing to pay a monthly premium

- under 65, if they have declared permanently disabled by the Social Security Administration for 24 months, have end stage renal, or have ALS

- helps cover inpatient care in hospitals, SNFs, hospice & home health care

- SNF:

* 3 day minimum hospital stay to access benefits for SNF care

* may be within 30 days of 3 day stay

*re-access if readmitted to SNF within 30 days

*100 days per benefit period (may change if dx changes)

- Benefit period:

*Begins w qualifying hospital stay & admitted to SNF

*ends: when no longer skills in for 60 consecutive days

*days remaining: if did not exhaust 100 days, pt has 60 days to re-access or new hospital stay

>0-30 days from end: same benefit period

>31-60 days from end: same benefit period, new hospital stay needed

>61+ days from end: new period & new hospital stay

- short stay acute hospital benefit for acute illness, disease or surgical care

- recovery after hospital often in SNF, home with home health or inpatient rehab

- those needing more than 25 days can receive in a long term care hospital

-Hospital Prospective Payment:

*1983: hospitals began PPS using case mix adjustments to predict resource utilization

*led to 751 medical severity diagnosis-related or MS-DRGs, similar model used in LTC

* resulted in a sharp reduction in inpatient utilization

* positive impact on OT/PT: need services to get out of the hospital, SNF, and home

- provides short term nursing/skilled rehab in Medicare certified unit per benefit period

- each resident is assessed used the RAI (Resident Assessment Instrument)

A. RAI has 3 parts:

1. Minimum Data Set (MDS): comprehensive decsription of the status & problems of the resident

2. the care areas assessment: triggered when there is a change in the MDS, structured process by the care team to identify, analyze, address the problem

3. the RAI utilization guidelines

B. Resource utilization Group: RUGS IV

- MDS: minimum data set done @ 5 set payments for 1-14 days, 14 day sets for payment for 15-30

- day of therapy: 15 minutes or more of treatment

- total minutes: actual # of minutes of therapy services provided in last 7 days

- therapy start date: date eval was completed whether treatment provided or ntot

- therapy end date: last day the resident received skilled services

- PPS: Perspective Payment System: 1998 Newest version in 2011

*reimbursement method that determines what services will be covered & how much will be paid for the services before they are delivered

*RUG basically the PPS used for patients under Med Part A

C. RUG Categories

- Ultra High Rehab plus extensive services

*720 minutes & IV feeding in last 7 days or IV, medications/tracheotomy care or ventilation/respirator in last 14 days AND ADL score of 7+

*720 minutes, 2 disciplines, 5 and 3x/week

- Very high rehab plus extensive services:

* 500 minutes

- High Rehab, plus extensive services:

* 325 minutes, 1 discipline 5x/wk

- Medium Rehab plus extensive services:

*150 minutes, 5 days any discipline

- Low Rehab plus extensive services:

* 45 minutes, 3 days any discipline

- Case-mixed model:

*used to classify residents into payment methods

- April 2017: Center for MEdicare & Medicaid Services (CMS) proposed new system for fiscal year 2018, Resident Classification System, Version I (RCS-I)

*Research & analyses conducted to dec the RCS-I model lead to many changes, including the name

*Transitioned into Patient Driven Payment Model (PDPM)

>USed ICD-10 dx procedural codes in order to classify SNF residents into 1/10 PDPM Clinical Categories

>Idea to provide connection btwn ICD-10 codes, procedure codes & 10 PDPM clinical categories

- Qualify based on home confinement & need for skilled services (rehab or nursing)

- MD must confirm homebound: cannot leave home except for med treatments or occasional community outing

- Can Med A or Med B

- Med A entitled to 100 visits if 3 day hospital stay within 14 days

- After 100 visit: no longer homebound then Med B

- All evaled using OASIS (Outcome & Assessment Info Set)

*Not be OT, ONLY PHYSICIAN & PT

- Hospice in HHC:

*Dx w terminal illness

*core services: nursing, social services, medicine, counseling

*OT & PT optional (may not be covered)

- Home health agency prospective payment:

* 60 day episode of care reimbursement to cover services

*does not cover DME

* determines a standardized prospective payment rate for each episode

*2012 the rate was $2,138.52 per episode

* Home Health Resource Group (HHRG): determines provider reimbursement

- Rehab hospital setting

- pt must need 3 hours of therapy 5 days/wk to quality: "three hour rule"

- "The 60% Rule": at least 60% of pt must be from certain pt diagnostic categories

- evaluated using the Inpatient Rehabilitation-Patient Assessment Instrument (IRF-PAI)

*Completed within 3 days of admission & 7 days of d.c

*used the Functional Independence Measure (FIM)

- Inpatient Rehab Prospective Payment:

*Info from IRF-PAI, med dx, and commorbidities are used to classify pts into case mix groups

*each group has weight that is multiplied by a national standard conversion factor, 2012 $14,109 per episode (varies based on commorbidities)

- req skills of qualified technical or professional health personnel

- must be provided directly or by under the general supervision of these skilled rehab personnel

- must be provided on a daily basis w need met w inpatient care w at least 5 days/wk

- services must be ordered by a physician (CMS Pub 100-02, Medicare Benefit Policy Manual)

- those eligible for premium free Med A are eligible for Med B

- Part B is optional, most enroll in both

- 25% Med B costs: paid by enrollees

- monthly premiums vary by annual income & addition of drug benefit

- $140 annual deductible & 20% coinsurance rate

- Benefits:

*pays for most of: prof services, outpatient, home health, DME, prosthetic, orthotics

Medicare Eligibility: Part B: Provider types

- all reimbursed used a fee schedule --> therapy must meet program requirements, settings have slightly diff rules

- Outpatient hospital:

*radiology, rehab, lab services: to community dwelling beneficiaries

- Comprehensive outpatient rehab facility (CORF)

*multidisciplinary provider for multiple rehab services in one location

>must have: physician, PT, and social services

>Addition: OT, SLP, respiratory therapist, nursing, prosthetic/orthotics

- OT/PT in private practice:

*solo practice, unincorporated partnerships, unincorporated group practices

*independent office w sufficient equipment

- Services shall be such a level of complexity & sophistication or the condition of the pt shall be such that the services req can be safely & effectively performed only by a therapist under the supervision of a therapist

- Skilled of therapist necessary to safely & effectively furnish a recognized therapy service whose goal is to improve an impairment or functional limitation

- clinician may dev maintenance program w therapist design plan, ensuring pt safety, edu/train fam/staff to continue w plan

- plan of care: must be certified by physician following therapy eval

- fee schedule

* Medicare physician fee schedule

* a list of procedure w associated payment, coded using Current Procedural Technology (CPT)

* often used codes in the 9700 series: Physical medicine & rehab section

* Med B premiums paid by annual income

- G-codes no longer req

*Functional reporting gathered data on the pt's functional limitations during a therapy session

> G-codes & modifiers were enacted from Jan 2013 until January of this year (2019)to convey info about the pt's functional status

*Why has it ended?

> AOTA& other therapy organizations have been advocating for the end of FLR for many years bc of the administrative & doc burden on our members

> CMS confirmed that collecting G-codes is not necessary or useful

- no mroe significant changes to CPT eval & treatment codes at this time

- Bipartisan Budget Act of 2018:

* January 2022 services provided "in whole or in part" by a therapy assistant (PTA or OTA) will receive 85% of the applicable Part B payment

- 3 mechanisms...

1. Sustainable growth rate

*complex formula that examines factors of growth & adjusts to limit overall costs

2. Multiple procedure payment reduction (MPPR)

*full practice expense portion is paid on the highest procedure on multiple procedure visits

*reduces expense 20-25%

3. Therapy Cap

*REPEALED

*The Medicare Access & CHIP Reauthorization Act of 2015

- therapists time spent on doc or on intial eval is not included (unless client present& participating)

- Therapist's time spent on subsequent re-evaluations, conducted as part of the treatment process, should be counted

- fam edu when resident is present is counted & must be documented in the resident's record

- only skilled therapy time (req skills, knowledge, & judgement of a qualified therapist & all req for skilled therapy are met

- shall not be recorded on the MDS

- time spent during which a resident received a treatment modality includes partly skills & partly unskilled time

*only time that is skilled may be recorded on the MDS

- therapist time during portion of treatment that is not skilled, during non-therapeutic rest period, or during treatment that does not meet therapy mode definition may not be included

- Med A:

*Max of 4 pt per clinicians

*participate in similar activity related to tx goals

*all minutes captured for each member

*max group minutes less than 24% of total treatment minutes during 7 day period

- Med B:

*max of 4 pts/clinician

*participate in similar or diff activities related to tx goals

* all minutes captured for each member

*no RUG categories

*no restriction on total group minutes during 7 day period

- therapist treats 2 or more pts @ same time

- Med B: NOT ALLOWED

Med A : concurrent for diff tasks, group if it is same task

- 2 therapists treat pt @ same time w diff treatment

- Med a: both disciplines may code the tx session in full, decision to co-treat should be made on a case by case basis & the need for co-treat should be well documented for each pt

- Med B: therapists or therapy assistants, working together as a "team" to treat 1 or more pt cannot each bill separately for the same or diff service provided @ the same time to the same pt

- now must doc why within the daily notes

- therapy services:

*OT/PT/SLP provided by a licensed provider

*OTA/PTA need general supervision

- condition of pt:

* skilled: eval, reeval, design POC, reg assessment of pt, pt & fam instruction, selection of AE

*maintenance not skilled, dev maintenance is skills, skilled to improve/maintain a progressively degenerative condition (Jimmo vs Sebelius Settlement 2013)

*Dx, age, comorbidities, social status, acuity/stability of conditions, risk if unskilled is done, prognosis = all determine need

- Coverage:

*determinations: rulles/guidelines to determine med necessity & claims

*databased under case of physician

- Plan of CARE:

*must follow pt dx, LT tx goals, type/procedures/amnt per day, frequency/wk & duration of therapy services

- Certification:

*Initial cert within 30 days, recert w/i 90 days

- Eval/Reeval

* demonstrate need for therapy services& outline POC

>pt inquiry by focus on therapeutic outcomes (FTO)

>activity measure for post acute care (AM-PAC)

> OPTIMAL by Cedaron by APTA

- Progress/Tx/Dc

*progress notes= 30 days or 10 visits w/e comes first

* treatment notes: daily or per visit, record pt's condition & response to tx, dated interventions, billing/time/codes

*d/c summary: last progress to d/c or the entire tx period review

- incident to therapy procedures

- when done by physician or non-physician practitioner considered therapy service under Medicare benefit

- Medicare prescription drug involvement & modernization act of 2003

- currently 25% receive benefits through Medicare Advantage

- Part C included

- pay premiums to manage care company other out of pocket costs can be imposed

- may also cover wellness visits, dental & vision

- benefits other than those in traditional medicare may be offered, no Part A

- 4 types of plans:

1. Medicare HMOs:

*most common form, typically cost less than traditional medicare

*benefits only within the plan network

2. Medicare PPOs:

*statewide or multistate network

*pay more for out of network, cost more than traditional Medicare

3. Private fee for service plans:

*provide paid on per service basis

*higher out of pocket costs

*providers can charge 15% more

4. Medicare special needs plan:

*new, those w chronic or disabling conditions, live-in institutions, or are Medicaid/Medicare eligible

- added in 2003, outpatient prescription drug benefit

- 2 mechanisms

1. stand alone prescription drug plan

2. plan to integrate into a Medicare Advantage

- to participate pay a monthly premium & other copays to access drugs @ reduced cost limited to the formularly or list of drugs covered by the plan

- coverage gap btwn $2400-$3850 must be under or over but will not cover amnts in btwn

- quality insured through 3 processes:

1. provider certification:

- providers must submit application to Medicare

- certification ensures providers are licensed & meet minimum req

- JCAHO for hospitals (accredits health organization)

2. Utilization review:

- internal: audit pt records, discuss POC, make recommendations

- External: by QIOs

3. Oversight by Quality of Improvement Organizations (QIOs)

- public reports available through websites for facilities

- G-codes (pt function, initial, anticipated dc, & actual d/c)

- multibillion dollar problem attributed to illegal beneficiary activity & unethical/illegal provider behaviors

*Level 1: review the utilization pattern against a standard "edit"

* Level 2: focused review by health professionals, review doc to determine if care meets Medicare guidelines; may result in denial or referral to level 3

* Level 3: onsite review of pt doc & billing records

- Fraud: making false statements or representation of material facts to obtain benefit or payment

- Abuse defined: any practice not consistent w the goals of providing pt w services that are medically necessary, meet professional standards & are fairly priced

- SNF Utilization & Payment Public Use File (SNF-PUF) March 2016

*data from 2013

*15,055 SNFs

* mroe than 2.5 million SNF stays

*almost $27 billion medicare payments

*Results: SNFs often provide therapy within 10 minutes of the minimum threshold of RUG categories

*list of practices in question: RehabCare settlement

-       Placing patient in highest therapy reimbursement level rather than relying on individual eval to determine the level of care necessary for each pt’s clinical needs

-       Scheduling/reporting the provision of therapy to pt’s even after the therapist recommends that the pt be d/c from therapy

-       Arbitrarily shifting the number of minutes of planned therapy among different therapy disciplines to ensure targeted therapy reimbursement levels are achieved, regardless of clinical need for therapy

-       Therapy not due to medical necessity but to reach minimum # of minutes req highest therapy reimbursement level to enable SNFs

-       Reporting estimated or rounded minutes instead of reporting the actual minutes

-       Reporting skills therapy has been provided to pts when they were asleep or sick

-       Couniting initial eval as time in therapy

Medicare Reform:

- Future challenges:

* current systen of controlling pricing is inefficient & diff to administer

* benefits package has not been comprehensively updated since the program inception

> Medicare has ^ through the years (larger gap of what medicare doesn't cover)

* older pop ^ will strain the system: less paying in & more taking out

- possible solution:

*change age of eligibility, expanding private managed care options