Healthcare Reimbursement, Fraud, and Malpractice

A patient requires inpatient rehabilitation following a stroke. Under the IRF 60% Rule, what is the minimum percentage of the facility's patients that must have specific qualifying conditions for the facility to be eligible for Medicare coverage?

A physical therapist in an outpatient clinic provides $90 minutes$ of therapeutic exercise, $30$ minutes of manual therapy, and $15$ minutes of gait training. According to the Medicare 8-Minute Rule, how many total units can the therapist bill for?

Which of the following scenarios is the BEST example of healthcare abuse, as opposed to fraud or waste?

A physical therapist documents in a patient's chart that the patient ambulated $100$ feet with a rolling walker. However, video surveillance shows the patient only walked $50$ feet. What legal concern does this discrepancy primarily raise?

A patient falls while ambulating in a hospital and sustains a hip fracture. To establish medical malpractice against the healthcare provider, which element would require demonstrating that the provider's actions (or inactions) directly caused the patient's injury?

Study notes on reimbursement, fraud, and malpractice in healthcare

Acute Care (DRG System)

Hospitals are reimbursed a single payment based on the patient's diagnosis

Inpatient Rehab (IRF 60% Rule)

Medicare coverage requires that at least 60% of patients have specific conditions

Skilled Nursing Facilities (SNF)

Only skilled therapy services are covered, not custodial care

Outpatient Therapy – Medicare B

There is an annual threshold for maximum covered therapy expenses before justification is required

KX Modifier

Used to indicate that therapy services have exceeded the set cap

Targeted Medical Review

Used to ensure compliance with billing requirements

Fraud, Abuse, and Waste (FAW)

Fraud involves intentional deception, such as billing for services that were not provided
Abuse refers to practices that lead to unnecessary costs, such as excessive testing
Waste is the inefficient use of resources, such as redundant treatments

HIPAA Regulations on FAW

Patient data is protected
Fraudulent billing practices are prevented

Billing Guidelines

The 8-Minute Rule (Medicare) calculates billing units based on the total time of services provided
The Substantial Time Rule (Commercial Insurers) requires each procedure to be billed separately

Elements of Malpractice

A duty to the patient exists when the provider has an obligation to deliver standard care
A breach of duty occurs when established standards are not met
Causation is when the breach of duty directly results in harm
Damages occur when the patient suffers financial or physical loss

Electronic Health Records (EHR)

Benefits include improved accuracy and accessibility
Risks include legal liability and documentation errors

Importance of Contemporaneous Documentation

Accuracy and reliability are both ensured
Legal exposure is reduced
Claims of fraudulent or altered records are prevented

Study notes covering healthcare reimbursement models including acute care, inpatient rehab, and skilled nursing facilities. Also covers fraud, abuse, waste, and HIPAA compliance. Includes outpatient therapy, the KX modifier, and targeted medical review.