Page 136 - Business Development Orientation Binder

Reimbursement

Major Sources of Reimbursement
A. Medicare
B. Medicaid
C. Managed Care (Commercial/HMO)
D. VNSNY Charitable Care
E. No Fault
F. Worker’s Compensation
G. Private Pay
A. MEDICARE
 A federally funded program that provides health care services for those over 65, and those
under 65 with chronic disability or ESRD/Dialysis
 Part A:
 Hospital
 Home Care
 Hospice
 Skilled Nursing Facility (20 days)
 Most Supplies
 Part B:
 Physician appointment
 Outpatient Treatment
 DME
 Part C:
 Medicare Advantage Plan
 e.g. Choice Medicare
 Part D:
 Medication Prescriptions

 Medicare Home Care Criteria
1. Homebound:
 Bed bound
 Inability to transfer/ambulate w/o assistance
 Inability to negotiate stairs leading from home
 Uses walls/furniture for support
 MD has specified limited activities, OR, patient has post surgical limitations
 Leaving home requires considerable and taxing effort
2. Service must be Skilled: Requires the skill of an RN, PT, or ST because it takes the education,
training, and expertise of these professionals to implement care.

Reimbursement 06-27-2017 Page 1 of 4