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Financing Ltc Powerpoint


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  • 1. Financing Senior Care
  • 2. Financing Broad Meaning
    • Mechanism to pay for health care services
    • - Medicaid is the primary source of
    • financing nursing home care
    • Reimbursement
    • - Actual payment for services delivered
    • - Methods used to determine the
    • amount of payment
  • 3. Recent Health Policy Objectives
    • Curtail direct reimbursement
    • Develop new methods of reimbursement that relate amount paid to the clinical needs of patients
    • Enrollment in managed care plans
    • Investigate and prosecute fraud and abuse
  • 4. Private-Pay Rate Setting
    • Non-bundled (room-and-board plus ancillaries)
    • Should be higher than Medicare and Medicaid rates on an all-inclusive basis
    • Governed by competition
    • Extra amenities and quality generally fetch a premium
  • 5. Medicare (Title 18)
    • Covers three categories of people:
    • - Age 65 and over
    • - Disabled people on Social Security
    • - People with end-stage renal disease
    • The program is not comprehensive in scope. Benefits are limited.
  • 6. Medicare Part A (HI)
    • Covers four main services:
    • Hospital inpatient services
    • SNF
    • Home health for skilled nursing care
    • Hospice care in a Medicare-certified hospice
  • 7. Medicare Part A – SNF coverage
    • Post-acute (at least 3 days of hospitalization is necessary)
    • Limited to 100 days per benefit period
    • A physician must certify the need for skilled nursing care
  • 8. Benefit Period
    • Triggered by a specific ‘spell of illness’
    • Continues when the patient is hospitalized or receives services in a SNF
    • Terminates when the patient remains out of a hospital or SNF for at least 60 consecutive days
  • 9. Medicare Part B (SMI)
    • Voluntary program that requires payment of a monthly premium
    • Covers outpatient services
  • 10. Deductible and Copayments
    • Deductible applies to each benefit period
    • Generally paid during hospitalization. Hence, most patients have met the requirement before they are admitted to a SNF.
    • Copayments apply from days 21 to 100 in a SNF
  • 11. Skilled Care vs. Custodial Care
    • Custodial care mainly requires ADL assistance or routine basic care
    • Skilled care is complex
    • Skilled care requires active involvement of professionals such as nurses and therapists
  • 12. Medicare Part B Benefits
    • Services of attending physician
    • Diagnostic services
    • Other outpatient services (see Exhibit 4-3)
  • 13. Medicare Reimbursement
    • Prospective payment system based on case-mix
    • Case-mix reflects a facility’s composite of clinical acuity
    • Case-mix is determined by an assessment of each patient using a standardized RAI
    • Per-diem, all-inclusive (bundled) rate
  • 14. Case-Mix Process
    • After patient assessment has been completed
    • Step 1: The patient is classified into one of
    • seven major categories
    • Step 2: The patient’s ADL score is calculated
    • Step 3: The patient is classified into one of 44 RUG categories based on index maximizing
  • 15. Medicaid
    • Title 19
    • For the indigent
    • Eligibility determined by each state
    • ‘Spend down’ is required if a person exceeds established resource levels
    • Community spouse is protected against impoverishment (Medicare Catastrophic Coverage Act 1988)
  • 16. Managed Care
    • Primary mechanism for health care delivery in the United States
    • Over 95% of employer-based health coverage is through managed care
    • But, approximately 57% of Medicaid and 18% of Medicare beneficiaries are covered through managed care
  • 17. Risk-Bearing Organizations
    • Include MCOs
    • They assume financial risk
    • Fixed monthly payments to these organizations are set in advance (prepayment)
    • The organization must provide all services needed by the beneficiaries
    • The organization is at risk of losing money if cost of services exceeds the fixed payments received
  • 18. Partnerships With Hospitals
    • Sponsorship agreement
    • Bed-reserve agreement
    • Shared service arrangement
    • Management contract
  • 19. Fraud and Abuse
    • False statements to patients
    • False billings
    • - billing for services not provided
    • - upcoding
    • Kickbacks in exchange for patient referrals
  • 20. Remedies for Fraud and Abuse
    • Criminal prosecution
    • Fines
    • Jail sentences
    • Expulsion from Medicare and Medicaid programs
  • 21. Prohibitions Under the False Claims Act
    • Providing and billing for services that are medically unnecessary
    • Providing and billing for noncovered services
    • Claiming payments for services that are covered in a bundled rate
    • Delivering inadequate care
  • 22. Qui Tam
    • Whistleblower provision
    • A private party can sue a violator on behalf of the government
    • Monetary recoveries are shared