PT Roles Quiz 2

Reimbursement

-getting paid for what we do -paid after services rendered

Stakeholders impacting reimbursement

-practitioners/employers -3rd party payers -federal law -state law -other funders

3rd party payers

-health plans -insurance companies -medicare/medicaid

state law

State of Illinois Early Intervention Program

other funders

Division of Services for Specialized Care for children

Where does physical therapist income come from?

-pay yourself/receive income from another person/organization -paid: hourly, salary, per service -revenue needs to be generated to pay clinicians

a provider receives payment based on

-bundle of services including physical therapy -specific physical therapy services -a block payment or grant

Insurance benefits are usually limited by

-number of visits per year/per episode/ per condition -maximum dollar amount per year -insurers may exclude specific techniques or conditions from coverage

Medicare coverage administered by

The Centers for Medicare and Medicaid

Medicare coverage

-amercians 65+ who have worked and paid into system -younger individuals with disabilities, end-stage renal disease and amyotrophic lateral sclerosis

what are the four parts of medicare?

Part A, B, C, D

Part A

inpatient hospital and skilled nursing care, home health care, hospice care

Part B

supplementary medical insurance, doctor's services, rehab therapy services, other outpatient care, supplies not covered by part A

Part C

-Medicare Advantage -provided by private companies that have approval -offer all in one hospital and medical insurance (prescription, dental, vision)

Part D

-prescription drug coverage -premiums vary and weighted by income

Skilled Nursing Facility

-Covered by medicare part A -Qualifying hospital stay -Cost -Medicare Part B may be provided based on nature of medical need and if outpatient

qualifying hospital stay

prior 3 day hospitalization (inpatient)

cost for SNF

-Days 1 to 20 = 0 -Days 21 to 100 = 194.80 coinsurance per day -Days 101 and beyond= all costs -prospective payment system

Prospective Payment System (PPS)

paid a predetermined rate for each day of care based on patient needs

Acute Care Hospitals

-Medicare Part A -inpatient care -payment based on predetermined per discharge rates -cost

inpatient care

diagnosis and treatment of acute conditions, manifestations of chronic conditions

Payment based on predetermined per-discharge rates

primarily related to condition and treatment

cost for acute care

-$1,364 deductible for each benefit period -Days 1-60: $0 coinsurance -Days 61-90: $341 coinsurance per day of each benefit period -Days 91 and beyond: $662 coinsurance per each “lifetime reserve day”

Outpatient Services

-Part B -Medically necessary diagnostic and treatment services -Emergency or observation services -Lab tests -Preventive and screening services -Cost

emergency or observation services

may include overnight stay

Cost of outpatient services

-20% of the Medicare-approved amount -Medicare deductible ~ $185 or greater (depending on income)

Outpatient PT

-Part B -covers 80% -Beneficiary covers 20% after deductible met -Medicare covers $2040 for PT and SLP before provider indicates care medically necessary

Medicaid Coverage

-public health insurance program for low income americans -PT, optional program, can be covered at variety of facilities -PT not optional

when is PT not optional under medicaid

-inpatient hospital service -medically necessary under the Early, Periodic, Screening, Diagnostic and treatment program in schools

Federal and State Level PT reimbursement

-department of Defense (TRICARE) -department of veteran affairs -individuals with Disabilities education act (IDEA)

Modes of healthcare financing in US

-out of pocket -individual private insurance -employment based group insurance -government social insurance

What are the types of insurance?

-Preferred provider organization -Health Maintenance Organization -High Deductible Health Plan -Point of Service

Preferred provider organization

-PPO -see any health provider in network without referral (PT vary), in-network lower than out of network

Health Maintenance Organization

-HMO -choose primary care physician who directs all services to in network members and specialists

High Deductible Health Plan

-HDHP -higher initial deductible cost but lower yearly or monthly premiums

Point of Service

-POS -combine HMO and PPO -greater than HMO -use out of network services

Deductible

-amount of money insured would need to pay before benefits from health insurance policy can be used -yearly amount

co-insurance

percentage amount that insured's responsibility -80/20 common split

Co-payment

fixed amount insured is required to pay at time of service

lifetime maximum

amount of money the health insurance policy will pay for entire life

Why do we need insurance?

important determinant to access health care

uninsured

-no usual source of care -less likely to see healthcare provider in last six months -unmet healthcare needs -worse outcomes

financial burden

-medical bills biggest cause of US bankruptcies

What are the three levels of evaluation codes?

-low complexity -moderate complexity -high complexity

low complexity

-no personal factors/comorbidities -examination of body systems: 1- 2 elements -stable and uncomplicated

moderate complexity

-1 to 2 personal factors -examination of body system: 3 or more -evolving

high complexity

-3 or more personal factors -examination of body system: 4 or more -unstable and unpredictable

Diagnosis codes: pathology

-ICD - 10 - CM -Owned by World Health Organization

Procedure codes - current procedural technology American medical

-association owns the copyright (AMA) -uniform language: increase accuracy and efficiency -required for private practice, outpatient hospital, and medicare part B SNF -evaluation codes = procedure codes -interventions codes --> gait training, manual therapy, therapeutic exercise

fraud

intentional deception or intentional misrepresentation that a person makes to gain benefit for which that person is not entitled

abuse

payment for times/services when there is no legal entitlement to that payment and health care provider has not knowingly and/or intentionally misrepresented facts to obtain payment

waste

over utilization of services or other practices that directly or indiscreetly result in unnecessary costs to healthcare system

consequences of fraud, abuse, and waste

-overutilization of services -increased costs for payers -corruption of medical decision making -unfair competition -harm to patients

false claims act

imposes liability on any person who submits a claim to the federal government that he/she knows is false

whistleblower provision

private individual to file lawsuit on behalf of the US for violation of false claims act

anti kickback statute

forbids receiving a payment for referring a patient for services, equipment, and any item that would be covered by medicare or medicaid -payment forms: cash, free rent, gifts distort medical decision making, cause over utilization, increase costs, result in unfair competition

physical self referral law (stark Law)

prohibits physical referrals of designated health services for medicare and Medicaid if physician has financial relationship with that entity

exclusion authorities

department of health and human services is required to exclude health care providers and suppliers who have been convicted of crimes from participation in federal health care programs

what are the crimes for exclusion authorities

-medicare/medicaid fraud -patient abuse/neglect -felony convictions for health care related fraud, theft, misconduct -felony convictions for unlawful manufacture, distribution, prescription or dispensing of controlled substances -default on government issued student loan

civil monetary penalties law

-office of inspector general may seek civil monetary penalties for variety of criminal violations

criminal violations for civil monetary penalties law

-presenting claim that person knows is for service/item not provided -presenting claim that person knows is for item/service that not eligible for payment

billing and documentation

-submit claim for services you are attesting that you have earned payment and are in compliance with all the billing requirements -documentation is professional responsibility and legal requirement -falsified documentation is violation of fraud and abuse laws

improper coding and billing

billing for services: -not provided -not medically necessary -by aides -provided by PTAs not properly supervised

professional relationships

-must be cautious about gifts to physicians or referral sources and cannot be with intent to encourage referrals -federal laws prohibit offering gifts to beneficiaries b/c can be seen as inducing patients to come to one practice -providing free services or waiving patient co-pays/deductibles is prohibited

if therapist observes/finds potential problem

-contact compliance officer -immediatley stop submitting problematic bills -seek knowledgeable legal counsel -determine whether there are overpayments that need returned -disentangle yourself from problematic relationships -consider reporting information to office for inspector general (OIG) or center for medicare/medicaid services (CMS)

administration law definition

claims brought against individuals of groups by administrative agencies which are created by gov to administer and enforce particular set of statutes

civil law

claims made by individuals, groups, or state to recover damages when noncriminal act has been committed against person or property

criminal law

event is considered act against society, gov brings criminal charges against perpetrators

laws impacting PT

-administrative law -civil laws -criminal law -insurance law -contract law -health care laws -employment laws

administrative law

-health service providers must be licensed to provide reimbursable clinical services -license is evidence that individual has met requirement of state practice act and qualified to practice -licensee must meet his/her responsibilities as states in practice act

purpose of Illinois physical therapy act

protecting the public health, safety and welfare, and for providing state administrative control, supervision, licensure, and regulation of the practice of PT

practice acts

-state laws enacted to protect residents -administrative law is determined by hearing panel consisting of health professionals and public representatives -responsibility of licensee to be aware of the practice act and associated rules and regulations -state boards can regulate professional conduct outside of patient interaction

scope of practice

range or responsibility; the types of patients and practice guidelines that determine the boundaries within which a professional practices

three kinds of scope of practices

-professional -jurisdictional -personal

two types of civil law torts

negligent and intential

negligence

omission/commission of an act that a reasonable and prudent person would/could not do under give circumstance

professional negligence

-malpractice -occurs when alleged wrongdoer is licensed professional and requisite action is within scope of practice, requiring knowledge and skills of professional

intentional tort

act that is intentionally committed knowing harm is likely result -assault -battery

assault

threat to touch another without consent

battery

intentional touching of another without his or her consent

for both ordinary negligence and malpractice plaintiff must prove which four elements exist?

-duty -breach -damages -causation

duty

duty owed to a person; legal duty exits whenever a healthcare facility/provider undertakes care/treatment of a patient

breach

demonstration that duty was not met, either by failure to act (omission) or by failing to meet the standard of care for the circumstance at the time

damages

the party who was owed a duty incurred damages

causation

causal relation between the breach of duty and damages that occurred

malpractice

-negligence case must meet all four elements and -expert witness testimony required to demonstrate ordinary professionals standard of care

malpractice event

this is what triggers the case -misunderstanding, accident, clearly defined injury

what to do as soon as the event occurs if you are aware it has occurred

-attempt to remedy the situation -alert appropriate health professional if you need additional professional assistance -document thoroughly, accurately, and objectively -likely facility has report to fill out for risk management

lawsuit is formally initiated when what two documents are filed

-summons -complaint

summons

written legal document given to the defendant in a law suit which names the defendant, plaintiff, jurisdiction, and when/where defendant should appear

complaint

gives detail about the case against the defendant and outlines the bassi of the suit

what should the defendant do upon receiving summons and complaint

-notify liability insurance carrier -notify employer -review all records -preserve all records

what should the defendant not do upon receiving summons and complaint

-distribute original record without advice from legal counsel -make changes to the records -converse about case with colleagues, family, friends, email

complaint and documentation

-documentation support what did and did not happen during patient session and patient/therapist interaction -incomplete documentation can not be supported later -most trails occur months/years after actual session

pre-trial

-both parties research relevant facts -oral depositions, written depositions, production of records -oral depositions taken under oath

if judgement is in favor for plaintiff in malpractice case

-financial consequences -employment consequences -licensure consequences, suspension, revocation -national practitioner data bank

unusual events/ incident/ investigations

-internal mechanisms for evaluating and understanding events, record keeping of the events = not discoverable -code huddles -safety huddles

advocacy

act of arguing in favor of something, expressing belief in someone, promoting an idea, campaigning for an action, or speaking for another

being an ADVOCATE FOR a person or entity

act to influence others on behalf of another's opinions, desires, needs

being an ADVOCATE TO a person or entity

act to influence the person or entity to adopt your opinions, desires, needs

patient advocacy

decision to advocate for the patient, organizational, professional, societal level is different than other patient management decisions -based on moral and/or ethical reasons

patient advocacy decision to act

address problem usually results from: -tradition -authority -trial and error -logical reasoning

tradition

concern that PT usually addresses

authority

organization the PT works for obligates a PT to address the problem

trial and error

PT has faced the problem before

logical reasoning

PT intellectually lays out what he/she knows about the problem, what can be done, and personal resources available and has decided to address situation

how does on advocate?

-examine problem -evaluate and diagnose -prognosis -select and plan interventions -implement intervention -reevalute the problem

current issues

-co pay equity -term protection

what activities constitute advocacy?

-organizing group -educate legislators -educating public about legislative process -educating public on what PT can do -research -organizing rally -regulatory efforts -public education -nonpartisan voter education

organizing group

build power at the base

educate legislators

provide information on the issues

educating public about legislative process

introduce communities and constituencies to legislators who represent them

research

produce relevant resource that reflect the real story of your community

organizing a rally

mobilize for your cause

regulatory efforts

take action at the agencies

public education

educate the community on the issues

nonpartisan voter education

inform the electorate on the issues

how does one effectively advocate with legislators?

-define the problem -identify all stakeholders -set a meeting or other form of cummincation

ways to build relationship with your representative

-office visit -practice visit -town halls -fundraisers

before you meet with your legislator

-be prepared -be unified -be informed

be unified

everyone participating int he list must be on the same page

be informed

-APTA/IPTA gov affairs staff -let state or national office know you have set up independent visit

first professional PT organization formed

-1921 -American Women's Physical Therapeutic Association -President: Mary Mcmillan

1940s

-American Physical therapy Association -house of delegates -board of directors

Association purpose

APTA improves the health and quality of life for individuals in society by advancing physical therapist practice

Association organizational values

-committed to excellence in practice, education, research, advocacy -respect the dignity and differences of all individuals and commit to being culturally competent and socially responsible association -lead with professionalism, integrity, and honesty -make decisions that reflect visionary thinking, innovation, collaboration, accountability

government structure of APTA

-Board of Directors -House of delegates -Chapter board of directors -state assembly -distrits -student special interest groups -sections/acadmies

house of delegates

-largest legislative body of APTA -primary decision maker -passes bills and items for board of directors -highest legislative body

board of directors

follow through on decision of the house, fiduciary responsibility of organization

delegates

-help to share development of policies and positions that direct associations mission, mission, goals, objectives, activities, and budget -direct future of profession and care we provide our patients

legislative and elective powers and authority of house

-determine policy of association -most significant legislative power -amend and repeal bylaws -adopt ethical principles and standards to govern conduct of members -charge board of director to carry out activities on behalf of organization -elect association officers

association officers

-president -VP -secretary -treasurer -speaker -director -nominating committee

house historic actions

-moved PT to post bachelors -developed code of ethics -developed and modified mission and goals of association -adopted vision 2020 and beyond 2020 -developed professional standards, policies, and positions and multiple practice related issues -adopted vision for PT profession

membership in house

-representative body -total size apportioned on number of members in state chapter -delegates elected at state level

voting delegates

physical therapist members who are chapter delegates

before 2020 - non voting delegates

-section delegates -study assembly delegates -PTA caucus delegates -members of board

2020 house of delegates motion

gave section/academies 2 votes

2021 house of delegates motion

-gave PTA caucus 2 votes -denied giving student assembly 2 votes

how does member advocacy work in the APTA

-any member concern can be brought to board member or assembly member of chapter -chapter board of directors can make motion or any assembly member can make motion -debated at board of directors meeting or state assembly -if concern/idea bigger than the state level the chapter representatives can bring motion to house of delegates or APTA board of directors

why does membership matte

-power of an organization is based on members -both in its political power and financial banking -membership causes discussion and idea formation about profession

APTA urges congress and administration to

-improve patient outcomes by eliminating barriers to health care services -enact policies that empower all people regardless of where they are born, live, learn, work, worship, and age to live healthy and independent lives -improve patient outcomes and patient satisfaction by improving health services delivery -prioritize research and clinical innovation to advance the science, effectiveness, and efficacy of physical therapist practice

formal code of ethics

-defines professional obligation -promotes public good -minimizes harm for public -allows professionals to negotiate organizational and societal arrangements -establishes ethical ideal for practice -provide core values and ethical principles -provide standards of behavior/conduct for professionals -educate general public and stakeholders about principles and standards -assist professionals in recognizing and resolving ethical dilemmas

is the formal code of ethics regulated?

no

is the code of ethics up to an individuals interpretation

yes and no

does the code of ethics apply to those who are not members of our professional association?

yes

ethics

systematic rational reflection on issues of right or wrong or regarding what we ought to do

values

subjective standards for what is right or wrong

laws

included rules, administrative codes, and regulations created by administrative agencies to interpret or implement legistlation

IDFPR

legal board for PT

important ethical documents

-code of ethics -guide for professional conduct -guide for conduct of the PTA

basic concepts of ethical decisions

-autonomy -beneficence -non maleficence -veracity -justice -paternalism -fidelity -respect for others

autonomy

right to self determination, personal freedom to chose

beneficence

promote good in actions

non-maleficence

preventing harm

veracity

telling the truth

justice

treating all persons fairly

paternalism

allow one person to make partial decisions for another

fidelity

faithfulness to patients interests keeping one's promises

types of ethics development

-personal -professional -societal

personal ethics

influenced by childhood beliefs and life experiences, social norms, authority figures, religion, and traditional and contemporary culture and beliefs

professional ethics

shaped by their underlying principles, values, beliefs

societal ethics

expects health professions to provide competent services in ethical manner

core values

-accountability -alturism -collaboration -compassion/caring -excellence -inclusion -integrity -duty -social responsibility

ethics development

-development of understanding of a professional standards -practice standards -billing/reimbursement standards -professional relationships -development of ability to work through ethical decision making process -provide opportunities to perform ethical analysis based on cases -managing desire to create black and white decisions in gray world

informed consent

respect the right of patient to make a decision about his/her health care, based on an understanding of necessary information

informed consent

legally adequate disclosure includes information concerning: -diagnosis -nature and purpose of treatment -risk of treatment or non treatment -treatment alternatives

purtillo's five reasonable expectations of healthcare workers

-basic respect -adherence to professional statements/standards -competence -following policies/statements of organization -honoring agreements reached between provider and patient

conflict of interest

-exists when competing interest or obligations that prevent fulfillment of primary professional obligations -professionals wherever possible should avoid conflicts of interest and the perception of conflicts of interest

examples of conflict of interest

-physician owned practice -treating one's own family members -having relationships with vendor you commonly utilize -investing in company whose product you utilize and order for patients -acute care therapist referring patients to only one outpatient facility

how do we do ethical analysis

-be fully aware of the facts -recognize all stakeholders -do step by step analysis -may need outside assistance in analyzing situation (ethics consult/committee within own organization)

ethics committees

do not give legally binding recommendations but can allow outside perspective and team to go through process with you and those involved

RIPS model

step by step analysis which is most appropriate for situations in which there are two competing ethical properties at stake

four steps of RIPS model

-recognize and define -reflect -decide -implement, reassess, evaluate

recognize and define

-when defining ethical situation you must first find out where the ethical situation is taking place -make sure that all facts are expressed before defining stage

Realms

-individual -organizational -societal

individual realm

-primary concern is the good of the PATIENT/CLIENT -focus is rights, duties, relationships, and behaviors between individuals

organizational realm

-primary concern is good of organization -focus on structures/systems that facilitate the organizational goals

societal realm

-primary concern is the common good -focus on legal, financial, constitutional, and cultural goals

individual processes

-moral sensitivity -moral judgement -moral motivation -moral courage

moral sensitivity

involves recognizing, interpreting, and framing ethical situations

moral judgement

requires deciding on right vs wrong actions -involves generating options, selecting, and applying ethical principles

moral motivation

places priority on ethical values over other values such as self-interests, status, financial gain

moral courage

involves implementing the chose ethical action, including development of plan and perseverance in face of barriers and adversity

situations

-issue -dilemma -distress -temptation -silence

issue

important values are present

dilemma

tow course of action may be taken, both of which fulfill duty, but is not possible to fulfill both obligations

distress

you know the right course of action but are not authorized or empowered to perform it

temptation

involves choice between a right and wrong in which you may benefit from the wrong choice

silence

ethical values are challenged, but no one is speaking about this challenge to values

stages 3 and 4

-decide and implement -evaluate -reassess

what are kidder's approaches to solving dilemmas

-rule based -ends based -care based

rule based

-follow the rules, duties, obligations, or ethical principles already in place

ends based

determine the consequences or outcomes of alternative actions and the good or harm that will result for all the stakeholders

care based

resolve dilemmas according to relationships and concern for others

recognizing ethical situations

-legal test -stench test -front page test -mom test -professional ethics test

legal test

is something illegal?

stench test

does it feel wrong?

front page test

how would you like this on the front page of your local newspaper?

mom test

if I were my mother, would I do this?

professional ethics test

does the code of ethics prohibit or discourage this?

resolving disputes

-examine the situation -review applicable laws, rules, and regulations -should I contact a third party? -talk with the PT or PTA -advice of counsel -employer/organizational grievance department -filing a complaint -insurance related issues -other third party agencies -APTA's ethics process

steps to taking action regarding ethical situations/issues

-organizational supports -initiate a report to IDFPR complaint department -contact ethics committee of APTA/IPTA

consequences of ethical situation at association membership level

-reprimand/censure -suspension -revocation

reprimand/censure

formal expression of disapproval

suspension

removal of membership for period of time

revocation

permanent denial of membership

consequences at state/licensure level

-probation -loss of license -loss of employment/future employment implications

what are the three behavior categories

-human error -at risk behavior -reckless behavior

human error

when a mistake was made that was not intended