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CCM: Case Management study guide: Chapter 6 healthcare reimbursement

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Women’s Health and Cancer Rights Act of 1998
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1. Part of Omnibus Appropriations Bill. 2. required group health plans to provide coverage for mastectomies and provide certain reconstructive related services following mastectomies.
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Women’s health and cancer rights act coverage
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1. reconstruction of the breast. 2. surgery and reconstruction of the other breast 3. breast prothesis 4. treatment for physical complications attendant to the mastectomy
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Women’s health and cancer rights act prohibitions
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Health plans are not allowed to deny anyone coverage for the sole reason of avoiding the requirements of the act AND cannot induce a physician to limit the care that is required under the act by penalizing or limiting reimbursement to the physician.
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Can states modify HIPPA’s portability requirement
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Yes. HIPPA requirements do not supercede state requirements. Stricter laws prevail. States can 1. shorten the 6 month look back period. 2. shorten 12 month maximum pre-existing condition exclusion period.3. increase the 63 significant break in coverage 4. increase 30 day period for new borns, adopted children, Children placed in adoption and pregnant women. 5. Expand the prohibitions on conditions and people to whom a pre existing condition excusion period may be applied beyond exceptions. 6. reduce additional special enrollment periods. 7. reduce maximum HMO affilation period to less than 2 months.
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Break in coverage
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63 days or longer that a subscriber has been without health insurance coverage (not including waiting periods)
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Waiting period
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period of time specified by health insurance contract that occurs between signing up for insurance and the beginning of health insurance coverage. Cannot be counted as creditible coverage time. Individuals can use COBRA from their previous employers for health insurance
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Establishing waiting period
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HIPAA does not prohibit plans from establishing a waiting period. But the waiting period and the pre-existing conditions exclusions must start at the same time and run concurrently.
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Creditable Coverage
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For the purpose of the Health Insurance Portability and Accountability Act, coverage under virtually any type indivual or group health care plan without a break in coverage of 63 days or more. Cannot be taken into account when determining a significant break in coverage. Only coverage after the 63 day break will be counted. Any coverage before the 63 day break will not be considered.
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COBRA
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Consolidated Omnibus Budget Reconciliation Act; law to provide terminated employees or those who lose insurance coverage because of reduced work to be able to buy group insurance for themselves and their families for a limited amount of time.
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Certification of creditable coverage
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Documentation that is provided automatically by the plan or issuer when the individual loses coverage or becomes entitled to elect COBRA continuation coverage and when an individual’s COBRA continuation covearage ceases ; Be provided if requested before loss of coverage or within 24 months of loss of coverage. May be provided through use of model certificate
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Nondiscrimination requirements
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Inividuals cannot be excluded from coverage under the terms of the plan based on specified factors related to health status. Health plans cannot establish rules of eligibility based on healht status related factors” such as health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability or disablity. Insurer cannot drop a patient from coverage because it knows that the patient will require a liver transplant next year. Cannot charge more for premiums based on health status.
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Security of health information and electronic signature standards
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provides a uniform level of protection of all health information that is housed or transmitted electronically. pertains to the individual.
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Tax Equity and Fiscal Responsibility ACT of 1982
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the purpose of this act is to control the rising cost of providing health care services to medicare beneficiaries and has incentives for cost containment. The act:1. established a case based reimbursement system (DRG) payment system determined the cost of care for selected diagnoses while also placing limits on rate increases in hospital venues. 2. Exempted medical rehabilitation from DRGs. Rehabiliation would continue as a cost based reimbursement system with limits. 3. Amended social security act so that group health plans pay before medicare for active employees 65-69 years old and for their spouses in the same age group. 4. revised Age discrimination act by requiring employers to offer health benefits to active employees 65-69 and their spouses in the same age bracket. 5. establish peer review organizations to reduce costs associated with the hospital stays of medicare and medicaid patients. Also established hospice benefit.
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The Mental Health Parity Act of 1996
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A statute that forbids health plans from placing lifetime or annual limits on mental health coverage that are less generous than those placed on medical or surgical benefits. Excluded substance abuse. If a plan does cover mental health, it cannot set a separate dollar limit from medical care. Other limits allowed: limited number of annual outpatient visits; Limited number of annual inpatient days; a per visit fee; Higher deductibles and copayments without parity in medical and surgical benefits. If a parity would require an increase of 1% or more in its health care costs, the plan would be exempt.
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The Pregnancy discrimination act
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is an amendment to Title VII stating that employment discrimination based on pregnancy, childbirth, or related medical conditions is prohibited as a form of sex discrimination
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Newborns and Mother’s Health Protection Act of 1996
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Health plans may not restrict benefits for any hospital length of stay in connection with child birth for new born or her bother to less than 48 hours following a normal vaginal delivery or less than 96 hours following a delivery by cesarean section. They may not require providers to request for authorization for up to 48/96 hours . May not increase an individuals coinsurance for any later portion of a 48 hour /96 hour hospital stay. 3. they cannot provide monetary payments to encourage a mother to accept less than minimum protections available under NMHPA. They cannot penalizeor other wise reduce or limit the reimbursement of an attending provider because the provider furnished care to a mother or newborn in accordance to NMHPA. They cannot provide monetary or other incentives to an attending provier to induce the provider to furnish care to a mother or new born in a manner inconsistent with the NMHPA.
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The Mental Health Parity and Addiction Equity Act of 2008
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MHPAEA preserves the MHPA protections and adds significant new protections, such as extending the parity requirements to substance use disorders. Although the law requires a general equivalence in the way MH/SUD and medical/surgical benefits are treated with respect to annual and lifetime dollar limits, financial requirements and treatment limitations, MHPAEA does NOT require large group health plans or health insurance issuers to cover MH/SUD benefits. The law’s requirements apply only to large group health plans and health insurance issuers that choose to include MH/SUD benefits in their benefit packages. However, the Affordable Care Act builds on MHPAEA and requires coverage of mental health and substance use disorder services as one of ten EHB categories
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Exceptions to MHPAEA 2008
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Except as noted below, MHPAEA requirements do not apply to: Non-Federal governmental plans that have 100 or fewer employees; Small private employers that have 50 or fewer employees; Group health plans and health insurance issuers that are exempt from MHPAEA based on their increased cost (except as noted below). Plans and issuers that make changes to comply with MHPAEA and incur an increased cost of at least 2% in the first year that MHPAEA applies to the plan or coverage or at least one percent in any subsequent plan year may claim an exemption from MHPAEA based on their increased cost. If such a cost is incurred, the plan or coverage is exempt from MHPAEA requirements for the plan or policy year following the year the cost was incurred. These exemptions last one year. After that, the plan or coverage is required to comply again; however, if the plan or coverage incurs an increased cost of at least 1% in that plan or policy year, the plan or coverage could claim the exemption for the following plan or policy year; Large, self-funded non-Federal governmental employers that opt-out of the requirements of MHPAEA.
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hard savings
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Examples of “hard” savings are directly linked to Case Management. Examples would be reduction in payer denials or decrease in avoidable days.
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soft savings
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Examples of “soft” savings are indirectly linked to Case Management such as lower readmission rates or lower post-op complication rates. These can be converted into dollars.
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1987 Nursing Home Reform Act
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The basic objective of the Nursing Home Reform Act is to ensure that residents of nursing homes receive quality care that will result in their achieving or maintaining their “highest practicable” physical, mental, and psychosocial well-being. To secure quality care in nursing homes, the Nursing Home Reform Act requires the provision of certain services to each resident and establishes a Residents’ Bill of Rights.
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CARF
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Commission on Accreditation of Rehabilitation Facilities
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JCAHO
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Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and previous to that the Joint Commission on Accreditation of Hospitals (JCAH),[1] is a United States-based nonprofit tax-exempt 501(c) organization[2] that accredits more than 20,000 health care organizations and programs in the United States.
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URAC
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accredits many types of health care organizations. Any organization that meets the standards, including hospitals, HMOs, PPOs, TPAs and provider groups can seek accreditation. Accreditation adds value to these programs by providing an external seal of approval, and by promoting quality improvement within the organization as part of the accreditation process.
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Wickline v. The State of California
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the point of this litigation is that a physician/surgeon is still responsible for negligently discharging a patient even if the financial benefits related to the hospital stay have been exhausted. Wickline also seems to suggest that a physician can be negligent for not acting more aggressively as a patient’s advocate with third-party payers.
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Reasonable accommodation may include, but is not limited to:
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-Making existing facilities used by employees readily accessible to and usable by persons with disabilities. -Job restructuring, modifying work schedules, reassignment to a vacant position; -Acquiring or modifying equipment or devices, adjusting or modifying examinations, training materials, or policies, and providing qualified readers or interpreters.
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The Individuals with Disabilities Education Act (IDEA)
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a law ensuring services to children with disabilities throughout the nation. IDEA governs how states and public agencies provide early intervention, special education and related services to more than 6.5 million eligible infants, toddlers, children and youth with disabilities.