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Terms in this set (138)
the VA, state departments, and county health departments are all examples of what?
government provider of services
for-profit and non-for-profit organizations are examples of what?
private providers services
medicare, medicaid, tricare, and workers comp are all examples of?
private pay (i.e. 1st party payer), employer-sponsored insurance, and private healthcare insurance are all examples of?
centers for medicare and medicare services (CMS), office of inspector general (OIG), occupational health and safety administration (OSHA), and state licensure boards are examples of?
private healthcare insurance, Joint Commission, commission on the accreditation on rehab facilities (CARF) are examples of?
3 steps to conflict resolution
1. present problem
2. resolve problem
3. consider interpersonal factors
licensure for PTs or PTAs is managed by the what?
individual state regulatory boards
each state has a ______ _____ for its laws, and they can differ from place to place
the NPTE test is _________ referenced?
FINHOP stands for
I: information management
P: planning and forecasting
3 domains of marketing
3. and people
these managers have a direct influence on the coordination and delivery of patient care though frequent interactions with the personnel they supervise and other managers
mid-level managers spend a great deal of their time (65%) on what?
5 roles mid-level managers play
5. future leaders
employees be paid at least the federal minimum wage for all hours worked and overtime pay at time and one-half regular work of pay for all hours worked more than 40 hours in oa work week
wage-based employees (non-exempt status)
exempt from FLSA is they are paid a salary of at least $455/wk rather than hourly wage= specific job duties and salary rather than job title determine exempt status
salary-based employees (exempt status)
employees paid agreed sum fee for a single unique job. if the fee is at a rate that would amount to $455/wk the employee exempt from FLSA
fee-based employees (may be exempt status)
this act currently requires employers to provide full-time employees health insurance coverage (full time = avg 30 hrs/week)
Affordable Care Act
this level of supervision: PT is not required to be onsite for direction and supervision, but must be available by telecommunication.
this level of supervision: The PT is physically present and immediately available for direction and supervision. The PT has direct contact with the patient/client during each visit
this level of supervision: The PT or, where allowable by law, the PTA is physically present and immediately available to continuously direct and supervise tasks that are related to patient/client management.
PT aides require what supervision?
PT and PTA students require what supervision?
PTAs require what supervision? (except private practice)
general; private practice is direct supervision
does Medicare deem services provided by a PT student working independently as billable?
basic unit of a healthcare business is made up of what 3 things?
3. healthcare provider
-reducing the number of employees who are eligible for health insurance benefits
- replacing a single expensive health insurance plan with a "cafeteria selection"
- increasing employee's contribution to pay for health insurance
are all examples of what?
how employers attempted to reduce some of their healthcare benefit expenses
according to the ______, proof of insurance is mandatory
medicare beneficiaries include people who are either
1. eligible for social security and are either 65 years old or older
2. or under 65 with certain disabilities
3.is any age with end-stage renal disease
people are automatically enrolled in part ____ of medicare when then?
A; they turn 65
this part of medicare provides health insurance for inpatient hospital services, short-term nursing home care and homebased healthcare; may have deductible and co-pays
part of medicare that is voluntary; provides insurance for outpatient health services including things like physical therapy, diagnostic tests, and visits to Dr; may have deductible and co-pays
AKA as the medicare advantage plan; has higher premiums but expanded benefits
medicare part C
medicare benefits are based on ______ ______
medical necessity= only cover medical services and treatments that are considered necessary and reasonable
enrollment is limited to people below a certain limited income and asset levels and each state creates and manages its own program
does medicaid pay for outpatient physical therapy services?
organization or entity that finances health care services for a pt or client
3rd party payer
the patient is considered what party?
the health care provider is considered what party?
one of the primary roles of 3rd party payers is what?
for a service to be covered under the medicare program, all of the following must be true
1. must have a benefit category in the statue
2. it must not be excluded
3. it must be reasonable and necessary
under the benefit policy manual (BPM), the following are 3 key elements for medicare documentation
1. medical necessity
2. reasonable and necessary
3. skilled services
services are considered to be ________ when the knowledge, abilities, and clinical judgment of a therapist are necessary
for medicare part B, a progress note must be documented in outpatient settings when?
at least once every 10 visits or once during a 30 day period, whichever is less
these codes are 3-5 digits in length with the first digit alpha (E or V) and the rest numeric; less detailed
these codes are 3-7 digits and are more specific
these codes are developed by the AMA for purpose of providing consistent and reporting procedures and service
CPT-4 (current procedural terminology)
this is the monthly cost to maintain health insurance coverage
this an absolute amount you pay to receive a service= amount the individual must pay each time services are used or prescription drugs are bought
this is a percent or portion of cost paid by the individual after the deductible has been met; the remainder paid by insurer; example after a $300 deductible, pt pays 20% and insurance company pays 80% up to a maximum-then insurance company will pay 100%
this is the amount of money you have to pay in order to receive service before health care plan pays any at all
pays for services to "maintain health" aka "Well baby visits" and must go through primary care physician as gatekeeper
HMO- health maintenance organization
is medicare a fee-for-service (FFS) program?
this is known as hospital insurance = Covers inpatient care in hospitals and inpatient stays in a SNF, hospice care services, and home health care services. Some individuals are automatically enrolled, others apply when eligible
medicare part A
AKA medical insurance = voluntary and individual must enroll during a specific period and pay required premiums; Covers physician services, outpatient care, some preventative services, and other medical services not covered by Part A such as ambulance, medical equipment, orthotics. subject to coverage and limitations
medicare part B
AKA medicare advantage (MA) Plan: provide Part A and Part B benefits and include prescription drug coverage and may also include other supplemental benefits
medicare part C
AKA: medicare prescription drug plan: voluntary plan that helps cover prescription drug costs
medicare part D
is someone has both medicare and medicaid, what happens?
paid first by Medicare and then by Medicaid, up to the State's payment limit
how are beneficiaries enrolled in medicare program?
through automatic enrollment or applying to program when eligible
this only works with the original medicare plan NOT the Medicare advantage plan= helps pay some of the health care costs that the original medicare plan doesn't cover
this is an organization that has an agreement with CMS to administer the medicare program with specific jurisdiction
medicare advantage contractors (MACs)
can a patient with ESRD get the MA plan?
how many G codes are therapists required to submit at reporting eval?
2= the current or discharge functional status and the projected goal functional status
expenses for delivering services, which include salaries, equipment (loans and leases) and clinical supplies-->inventory contol is important to controlling these costs related to clinical and office supplies so that sufficient quantities are available when needed while avoiding the expense of stockpiling excess supplies for extended periods of time
aka overhead costs: rent or mortgage payments, utilities, janitorial services, equipment maintenance, office supplies, and everything that underlie the direct delivery of services;
items necessary regardless of the number of patients that are in a practice or service; ex if only 1 patient the practice needs temperature, software packages, telephone, etc
indirect (overhead) costs
the same cost regardless of the number of patients who are treated (rent, loan payments)
the cost increases as the number of patient increases (laundry services)
a fixed cost, such as wages and salaries that may vary because of the need for overtime or when work hours are decreased as patient census fluctuates
in an effort to improve healthcare, it should be STEEEP; this was so health care organizations would have a better idea of what they needed to improve
improving the percent of clinic patients achieving their goal blood pressure by instituting a series of reminders for providers about evidence-based processes is an example of?
increasing the effectiveness of care
through staff development and weekly feedback, equalizing the likelihood that a patient will receive pain medication regardless of race, ethnicity or education is an example of?
increasing the equity of care
the 4 components of the system of profound knowledge include:
1. appreciation of a system
3. theory of knowledge
4. human behavior
this is an example of what component in the system of profound knowledge? My coworkers and my husband are resistant to my improvement idea (and my coworkers are routinely late for the carpool) because they are tired in the morning.
psychology (human behavior)
this is an example of what component in the system of profound knowledge? On one day no one was late and it was school vacation week so there were no buses to hold us up — we got to work earlier than any other day!
this is an example of what component in the system of profound knowledge? When one of my coworkers is late for the carpool in the morning, it affects the traffic we hit, what roads we can take, what parking space we can get, and, ultimately, the time we arrive at work.
appreciation of a system
this is an example of what component in the system of profound knowledge? If I can convince my husband and coworkers to go to bed earlier at night, they won't mind getting up earlier, and we will all get to work 30 minutes earlier and be happier and more productive.
theory of knowledge
this is known as the process of identifying potential threats that could severely damage or completely ruin an organization and taking action to reduce those risks; it is about processes to avoid accidents, to decrease liability when incidents occur, and to improve the quality of care
failure of risk management has serious ________ implications for healthcare organizations
these risks are beyond the control of managers (natural disasters) -demand property damage insurance coverage
this may be the BIGGEST financial risk for independent practitioners in healthcare
market risks; change in target markets
this type of risk is involved with the way work is conducted
this is a powerful risk management tool and is the single most important evidence of the PT's judgement, actions, skills, and decision-making
1. Find a problem
2. Organize a team
3. Clarify current process
4. Understand the causes of variation
5. Select a new process
the following should be included in an incident report:
1. date and time of incident
2. name of person involved
3. age, sex, diagnosis, and physician
4. description of event
5. name and contact of witness
6. witness's description of event
7. treatment offered/rendered
8. name, title, position of person reporting
a broad statement of an expectation that guides decisions regarding actions to be taken; general rules; addresses who, what, when, and where
describes a particular way of accomplishing an action; is a series of steps of how to carry out a policy
this is about the future and establishes premise for the business-->what it seeks to become and sets the direction; an estimated date is necessary
this follows the vision and focuses on what it needs to get there: is the current state of where you are, what you are doing, what you need (purpose)
values and beliefs, expected behaviors of employees and plans of organization; often starts with "we believe" and gives reason of mission and support of vision
these clarify specific work to be done and give accountability
goals must be SMART
essential legal framework of corporation that typically addresses procedures for holding meetings, electing officers, and defining duties and powers of corporation→ are adopted to provide detailed implementation of articles of incorporation
systematically developed statements based on established standards to assist in the decision-making of practitioners and patients about appropriate healthcare for specific clinical conditions → are about deciding
clinical practice guidelines
the activity, set of institutions, and process for creating, communicating, delivering, and exchanging offerings that have value for customers, clients, partners and society at large
4 Ps of marketing
in marketing, the goods, services, and ideas offered by an organization (lasting loyal relationship often considered product of healthcare for marketing)
in marketing, the charge for the product including professional fees, insurance premiums, deductibles, and co-payments
in marketing, the manner in which goods and services are distributed to consumers→ enhances perceptions of quality and includes communication that aren't face-to-face like online, phone calls, etc
in marketing, any means used to inform a market that an answer to its need is available to facilitate an exchange → a mix of advertising, sales, sales promotion, and publicity
marketing research to identify potential customers, and their needs, the means to meet those needs, analysis of competition, and positioning and pricing a new service (finding a niche)
promotion of product or service through advertising, public relations, and sales strategies
in the SWOT, strengths and weakness are both ______ factors
in the SWOT, opportunities and threats are both______ factors
a tool for comparing competitors and can be used to identify initiatives to improve their competitive position
an internal document that clarifies and verifies why a potential business is worth pursuing
7 Ps of marketing
7. physical evidence
the only element of marketing that generates revenue
in marketing, anyone who comes into contact with customers
in marketing, giving a service and the behavior of those who deliver like waiting times, and can often be the first experience of a company that many customers have
in marketing, this includes things like testimonies and feedback for customers to "see" what they are buying
this prohibits false claims for reimbursement to the government, getting paid for a false claim or falsifying a record to get paid
false claims act
Reduces fraud through a coordinated national program of federal, state, and local law enforcement
Provides national standards for electronic healthcare transactions; national identifiers for providers, health insurance plans, and employers; standards for security and privacy of health information
HIPAA Title II
knowingly and willing scheming to defraud a benefit program by false or fradulent pretense to obtain money or property from a health benefit program; examples include falsifying documentation, altering claim forms to receive a higher payment amount, using unlicensed individuals to provide services
obtaining payment that results in unnecessary costs to Medicare through payment for services that fail to meet professional recognized standards of care, are billed inappropriately, or that are medically unnecessary but person hasn't done it knowingly/intentionally; examples include misusing codes, charging excessively,
this is perhaps the biggest risk issue for hospitals and healthcare systems
overutilization of services or other practices that result in unnecessary costs to health care system and usually caused by payment errors called "improper payments"; examples are spending on services that lack evidence, failure of care coordination resulting in unnecessary hospital readmissions
this prohibits anyone from "knowingly and willingly" receiving a form of payment in return for referring a pt to another provider for services or items covered by Medicare and Medicaid
anti-kickback statute (AKS)
prohibits physician referrals of designated health services for Medicare and Medicaid pts if the physician or immediate family member has a financial relationship with that entity unless an exception applies
physical self-referral law (stark law)
3 realms of managed care ethics
2. organizational or insitutional
In RIPS, this is the least complex, concerned with the good of the pt/client and focuses on rights, duties, relationships and behaviors between individuals
in RIPs, this realm is concerned with the good of the organization and focuses on structures and systems that will facilitate organizational or institutional goals
organizational or institutional
this realm is he most complex that is concerned wit h the common good
4 parts of individual process in RIPS
1. moral sensitivity
2. moral judgment
3. moral motivation
4. moral courage
in the individual process of RIPS, this is recognizing, interpreting, and framing ethical situations
in the individual process of RIPS, this is deciding on right vs wrong actions; involves generating options, selecting and applying ethical principles
in the individual process of RIPS, this places a priority on ethical values over other values such as self-interest, status, or financial gain; professionalism is the key
in the individual process of RIPS, this is implementing the chosen ethical action, including the development of a plan and perseverance in the face of barriers and adversity
the 5 situations a PT or PTA may encounter in RIPS
1. issue or problem
in the RIPS model this situation is where important values are present or may be challenged
issue or problem
in the RIPS model this situation is where there are "2" right courses of action
in the RIPS model this situation this is where you know the right course of action but are not authorized to perform it; often identified during the implementation phase of decision making
in the RIPS model this situation is "right" vs "wrong"; you may stand to benefit from doing the wrong thing
in the RIPS model this situation is when ○ ethical values are challenged, but no one is speaking about this challenge to values. Maybe the course taken by an individual in moral distress
4 steps for implementing RIPS
1. recognize and define ethical issues
3. decide to do right thing
4. implement, evaluate, reassess
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