Payment and Reimbursement Exam
Questions and Answers
why measure outcomes of healthcare? - ANS-so we can deliver more affordable care
and superior health focused outcomes
outcome measures help assess what? - ANS-progress toward the goals of healthy
people and better, affordable care.
what are outcomes of healthcare? - ANS-1-learning
2-improved performance
3-e of superior outcomes
4-preperation for value-based payment
what are the way to measure quality healthcare? - ANS-1-structural
2-process
3-outcome
4-patient experience measures
5-composite
what are structural measures? - ANS-providers' capacity, systems, processes
-This includes things like physical structures, electronic systems, ratio of providers to
patients
what are process measures? - ANS-how providers maintain or improve health
outcomes
-This includes things like % of people receiving preventative medicine (mammograms,
Immunizations) , referral to eval timeframe, % of patients/caregivers who received
patient education prior to d/c
what are outcome measures? - ANS-impact services have on patients' health status
-This Includes measures like surgical complications, hospital-acquired infections,
discharge location(home vs SNF)
types of health insurance - ANS--medicare
-medicaid
-private
-self-pay
-professional organizations
, medicare part A - ANS-Inpatient coverage, home health, hospice. Also defines limits of
Medicare usage
medicare part b - ANS-pays for physician services, outpatient hospital services, durable
medical equipment, and other services and supplies.
medicare part c - ANS-Combines parts A and B covers all medical services needed
Medicare part d - ANS-Prescription drug coverage
medicare requirements for OT - ANS--must be prescribed by a physician and written
POC approved by physician (referral from physician)
-Must be signed and diagnosis must be acute in nature
-must be carried out by qualified OT or OTA supervised by an OT
-requires the skills of therapist or assistant
-specific to OT; Medicare will not reimburse duplication of services
-Reasonable and necessary to treat illness or injury
ICD-10 codes - ANS--uniform codes describing person's condition or medical reason for
services (Ex. Cerebral Palsy, unspecified G80.9; Alzheimer's Disease G30)
CPT codes - ANS-billing codes for medical, surgical and diagnostic services
-part of the Healthcare Common Procedure Coding System (HCPCS)
evaluation codes for OT are based on what? - ANS-complexity (high, moderate, low)
OT's use ICD-10 codes for what? - ANS-for treatment diagnostic codes - not diagnosing
medical conditions.
who processes medicare claims? - ANS-Medicare Administrative Contractor (MAC)
Medicaid covers how many OT visits annually? - ANS-30
Deductible - ANS-Amount you must pay before you begin receiving any benefits from
your insurance company
Co-pay - ANS-the amount of money the patient has to pay upfront that the insurance
company will not pay
what are essential health benefits? - ANS--Ambulatory patient services (outpatient care
you get without being admitted to a hospital)
-Emergency services
-Hospitalization (like surgery and overnight stays)
-Pregnancy, maternity, and newborn care (both before and after birth)
-Mental health and substance use disorder services, including behavioral health
treatment (this includes counseling and psychotherapy)
Questions and Answers
why measure outcomes of healthcare? - ANS-so we can deliver more affordable care
and superior health focused outcomes
outcome measures help assess what? - ANS-progress toward the goals of healthy
people and better, affordable care.
what are outcomes of healthcare? - ANS-1-learning
2-improved performance
3-e of superior outcomes
4-preperation for value-based payment
what are the way to measure quality healthcare? - ANS-1-structural
2-process
3-outcome
4-patient experience measures
5-composite
what are structural measures? - ANS-providers' capacity, systems, processes
-This includes things like physical structures, electronic systems, ratio of providers to
patients
what are process measures? - ANS-how providers maintain or improve health
outcomes
-This includes things like % of people receiving preventative medicine (mammograms,
Immunizations) , referral to eval timeframe, % of patients/caregivers who received
patient education prior to d/c
what are outcome measures? - ANS-impact services have on patients' health status
-This Includes measures like surgical complications, hospital-acquired infections,
discharge location(home vs SNF)
types of health insurance - ANS--medicare
-medicaid
-private
-self-pay
-professional organizations
, medicare part A - ANS-Inpatient coverage, home health, hospice. Also defines limits of
Medicare usage
medicare part b - ANS-pays for physician services, outpatient hospital services, durable
medical equipment, and other services and supplies.
medicare part c - ANS-Combines parts A and B covers all medical services needed
Medicare part d - ANS-Prescription drug coverage
medicare requirements for OT - ANS--must be prescribed by a physician and written
POC approved by physician (referral from physician)
-Must be signed and diagnosis must be acute in nature
-must be carried out by qualified OT or OTA supervised by an OT
-requires the skills of therapist or assistant
-specific to OT; Medicare will not reimburse duplication of services
-Reasonable and necessary to treat illness or injury
ICD-10 codes - ANS--uniform codes describing person's condition or medical reason for
services (Ex. Cerebral Palsy, unspecified G80.9; Alzheimer's Disease G30)
CPT codes - ANS-billing codes for medical, surgical and diagnostic services
-part of the Healthcare Common Procedure Coding System (HCPCS)
evaluation codes for OT are based on what? - ANS-complexity (high, moderate, low)
OT's use ICD-10 codes for what? - ANS-for treatment diagnostic codes - not diagnosing
medical conditions.
who processes medicare claims? - ANS-Medicare Administrative Contractor (MAC)
Medicaid covers how many OT visits annually? - ANS-30
Deductible - ANS-Amount you must pay before you begin receiving any benefits from
your insurance company
Co-pay - ANS-the amount of money the patient has to pay upfront that the insurance
company will not pay
what are essential health benefits? - ANS--Ambulatory patient services (outpatient care
you get without being admitted to a hospital)
-Emergency services
-Hospitalization (like surgery and overnight stays)
-Pregnancy, maternity, and newborn care (both before and after birth)
-Mental health and substance use disorder services, including behavioral health
treatment (this includes counseling and psychotherapy)
