Payment and Coding
Which codes determine the complexity of an OT evaluation? What are they?
CPT codes
Low
Moderate
High
When practitioners choose to provide services on a cash-pay basis and not accept health insurance, what services are they providing?
out of network services
Among all injuries and illnesses, what is the leading reason that U.S. employees are unable to
work?
Musculoskeletal injuries
Who monitors health and safety for work environments?
OSHA
This is the set amount of money that an insurance subscriber pays (usually) monthly in order to access their plan? What is the set amount paid for healthcare each year before the insurer will begin to cover the costs of certain services?
Premium
Deductible
What is reimbursement contingent upon?
processes and outcomes achieved by providers
True/False: Private insurance coding requirements for OT services vary between companies and within companies.
True
After a client completes a traditional medical management of an injury, what does the OT do next?
functional capacity evaluations, ergonomic evaluations, work conditioning, work hardening, and transitional work
What are the four types of worker's compensation programs?
Third party/private insurance
state run programs
self insurance
federal programs
What do direct medical expenses encompass?
hospitalization, physician visits, diagnostic tests, surgical procedures, outpatient procedures, rehabilitative interventions, drug and prescription costs
An OT has fabricated an orthosis for a client. What type of code would be used for billing?
L codes from CMS
What managed care plan offers clients OT services at lower costs if they select a certain provider?
preferred provider organization
When did the Mental Health Parity and Addiction Equality Act go into full effect? What may impact its effectiveness?
July 1, 2014; There are complex exceptions, inclusions, exclusion criteria and how private health insurance companies structure/regulate their policies.
What is the most common wage loss benefit that is payed to an employee that must take time away from work while recovering from a work-related injury?
Temporary Total Disability (TTD)
What is the 6th leading cause of death in the US? (IOM, 2009)
lack of health insurance
What are the four categories providers are graded on in the merit-based incentive payment system under Medicare B?
quality
cost
advancing care information
improvement activities
In what settings are OTs expected to contract with private health insurance plans?
Private practice
Who must provide high quality clinical services and develop expertise in multiple payer requirements? What are they multiple payer requirements?
Occupational Therapists
network enrollment
coding
billing
appeals
What claims make up to 75% of worker's compensation claims?
medical only claims
What may occur in out of network services?
Surprise medical bills
(significant out of pocket costs)
What are the five performance measures to measure value?
structural measures, process, outcomes, patient experience, patient reported
What are some ways that OT practitioners stay informed regarding private health insurance coverage policies?
Read coverage policies, including criteria for coverage and coding of occupational therapy services; Opt in to provider updates to receive notification when policies are added, deleted, or changed; Identify key contacts to call with questions about cov-
erage criteria or private insurance claims.
What program helps to support the development of work-based policies and cultures that comprehensively promote protection from work-related injuries, prevention of chronic illnesses, and development of employee well-being?
Total Worker Health
What is permanent partial disability calculated by?
Based on count of body parts or percentage of body affected or impaired by the injury
OR
calculated the same way as other types of disabilities that impair functional performance
What is the most common alternative payment model? What is the difference between this model and MIPS?
Accountable Care Organization
It allows providers within a facility to personalize reimbursement based on the specific population they treat.