Medicare is regulated at the ________________ level (federal or state)
federal
Medicaid is regulated at the _________________ level (federal or state)
state
What determines medical necessity? Is it automatically assumed it is necessary if the MD refers it?
no. up to OT's to decide if necessary
What determines medical necessity? Do OTs/PTs set the requirements?
No. Have to always defend why their services are medically necessary. Insurance sets requirements
What determines medical necessity? Is it justified by our documentation and plan of care?
yes
On what population is the majority of dollars in medicaid actually spent?
adults and older adults with disabilities
What population is most likely to be covered by medicaid?
children and women coming from low income
What is the major factor of medicaid eligibility?
income
The State Children's Health Insurance Plan targets what population?
children under 19 and children and families who earn too much that don't qualify for Medicaid
What is the functional use of CPT and HCPCS codes?
to bill for services
What is required for services to get paid under medicare? (i.e. what are they looking for in order to pay?) MD order alone?
Yes
What is required for services to get paid under medicare? (i.e. what are they looking for in order to pay?) A reasonable length of service?
yes. reasonable considering the patient's condition
What is required for services to get paid under medicare? (i.e. what are they looking for in order to pay?) The treatment plan is likely to produce functional improvements?
yes
Can OT start a plan of care for home health?
no. can only eval. PT, Speech, and Nursing have to skill qualify the patient first
What is a common assessment used to determine functional progress under Medicare?
FIM