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Financing Ltc Powerpoint

Financing Ltc Powerpoint






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    Financing Ltc Powerpoint Financing Ltc Powerpoint Presentation Transcript

    • Financing Senior Care
    • 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
    • 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
    • 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
    • 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.
    • 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
    • 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
    • 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
    • Medicare Part B (SMI)
      • Voluntary program that requires payment of a monthly premium
      • Covers outpatient services
    • 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
    • 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
    • Medicare Part B Benefits
      • Services of attending physician
      • Diagnostic services
      • Other outpatient services (see Exhibit 4-3)
    • 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
    • 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
    • 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)
    • 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
    • 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
    • Partnerships With Hospitals
      • Sponsorship agreement
      • Bed-reserve agreement
      • Shared service arrangement
      • Management contract
    • Fraud and Abuse
      • False statements to patients
      • False billings
      • - billing for services not provided
      • - upcoding
      • Kickbacks in exchange for patient referrals
    • Remedies for Fraud and Abuse
      • Criminal prosecution
      • Fines
      • Jail sentences
      • Expulsion from Medicare and Medicaid programs
    • 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
    • Qui Tam
      • Whistleblower provision
      • A private party can sue a violator on behalf of the government
      • Monetary recoveries are shared