Private Health Insurance
Define a covered health care service.
A healthcare service that is paid for in whole or in part under a coverage policy is a covered service.
What is a lost time claims?
When a injury or illness prohibits a person from carrying out the essentials of a job in a safe and effective way.
What does CMS stand for?
Centers for Medicare and Medicaid Services
What does EHR stand for?
Electronic Health Record
TRUE/FALSE
Could an occupational therapist be required to contract with a private health insurance plan?
TRUE
What is the most common subtype if private health insurance as of 2016?
employer-sponsored insurance
List the types of Workers Compensation programs
Self-insurance
State-run
Private/Third Party
Federal
What is the largest third party payer in the U.S.?
Medicare
What is a Deductible?
Set amount of money a client must pay for health care each year out of pocket, prior to obtaining services at a lower cost.
What type of injury/illness is the leading reason U.S. employees are unable to work?
Musculoskeletal Injuries
The Newborns' and Mothers' Health Protection Act of 1996 establishes ________ ?
Protections for hospital stay coverage for mothers and newborns in connection to labor, delivery, and recovery.
What is the most common workers compensation claim?
Medical-only claims
TRUE/FALSE
Private practice therapist who are enrolled as medicare providers can provide in-home services even if the client is not home bound/without any other qualifying service?
TRUE
Define co-insurance
Money that a client is required to pay for services and is often specified by a percentage.
Ex: Insured client pays 20% toward the charges for a services and the insurance company pays 80%
List the most common services an OT provides to ensure workplace safety and health promotion.
Job analyses & ergonomic analyses
What are some common Managed Care Plans?
Health Maintenance organizations (HMO)
Preferred Provider Organizations (PPO)
Point of Service (POS)
Exclusive provider organization (EPO)
A worker sustained an injury resulting in having to take 3 months off of work, what type of wage loss benefit will be paid to the employee?
Temporary total disability
Those who are covered by Medicare, what is the percentage of cost they must pay for outpatient services?
20%
Define no-fault workers compensation
Guarantee payment for medical expenses for a work-related injury or illness without either the employer or the employee being identified to have been at fault
Reimbursement can occur for an OT when the service is _____, ______, and _______.
Describe what occurs when a individual holds more than 1 health insurance plan?
Each plan must coordinate benefit rules and determine which plan becomes the primary and secondary payer.
Provide an example of a vulnerable population, who have more at risk jobs, according to Workers Compensation.
Low-income minorities, immigrants, undocumented groups.
List the steps of the service-payment cycle
1. OT services
2. Documentation
3. Coding
4. Billing
5. Reimbursment
What is a medical reviewer?
Someone hired by a insurance company to review documentation and determine wether the services are covered by the insurance policy.
An OT is seeing a client covered by Medicaid, what is the definition of a skilled service covered by Medicaid?
Any service that is necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.