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A resident’s personal needs allowance is an amount required to be deducted from the computation of a resident’s patient liability to be used for the purchase of goods and services of the individual’s choosing that are not covered under Medicare or Medicaid. Personal Need Allowance (PNA) Accounts and Other Resident Funds for Nursing Facilities (NFs)” paragraph (B)(2) states
that “The PNA account is the exclusive property of the resident, who may use the funds in the account as he or she chooses to meet personal needs.”(emphasis added) Examples of items and services that the resident may request which would be chargeable to their PNA account includes, but is not limited to, items such as personal clothing, reading materials, and social events or entertainment offered outside of the facility’s activities program.

Though not required to, the resident may request the assistance of the NF to manage their PNA account. If the resident requests such assistance through written authorization, the funds still remain the property of the resident to use as they choose and are to be released, up to and including the resource limit amount, to that resident upon discharge. OAC 5101:3-3-16.5(G)(2) specifically states that “Other than for items and services that the resident has requested and that may be charged to the resident’s PNA account in accordance with this rule, a NF provider shall not withhold PNA account funds to pay any outstanding balance a resident owes the provider at the time of discharge.”(emphasis added) Likewise, upon the death of the resident, the balance of the resident’s PNA funds become a part of the deceased resident’s estate.

Further reading –

https://www.cga.ct.gov/PS99/rpt%5Colr%5Chtm/99-R-0025.htm

The Total Cost of Care (TCOC) includes all costs associated with treating members including professional, facility inpatient and outpatient, pharmacy, lab, radiology, ancillary and behavioral health services.

Further reading –

https://www.qualitymeasures.ahrq.gov/summaries/summary/38363?

Per Member Per Month – This measure is used to assess the total cost of care population-based per member per month (PMPM) index.

Further reading –

https://www.qualitymeasures.ahrq.gov/summaries/summary/38363?

The Public Health Accreditation Board is a 501(c)3 nonprofit organization dedicated to improving and protecting the health of the public by advancing and ultimately transforming the quality and performance of state, local, tribal, and territorial public health departments.

Further reading –

http://www.phaboard.org/

Payment Error Rate Measurement Program –

The Improper Payments Information Act (IPIA) of 2002 (amended in 2010 by the Improper Payments Elimination and Recovery Act or IPERA) requires the heads of Federal agencies to annually review programs they administer and identify those that may be susceptible to significant improper payments, to estimate the amount of improper payments, to submit those estimates to Congress, and to submit a report on actions the agency is taking to reduce the improper payments. The Office of Management and Budget (OMB) has identified Medicaid and the Children’s Health Insurance Program (CHIP) as programs at risk for significant improper payments. As a result, CMS developed the Payment Error Rate Measurement (PERM) program to comply with the IPIA and related guidance issued by OMB.

The PERM program measures improper payments in Medicaid and CHIP and produces error rates for each program. The error rates are based on reviews of the fee-for-service (FFS), managed care, and eligibility components of Medicaid and CHIP in the fiscal year (FY) under review. It is important to note the error rate is not a “fraud rate” but simply a measurement of payments made that did not meet statutory, regulatory or administrative requirements. FY 2008 was the first year in which CMS reported error rates for each component of the PERM program.

Further reading –

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicaid-and-CHIP-Compliance/PERM/index.html?redirect=/PERM

The Office of Management and Budget (OMB) is the largest office within the Executive Office of the President of the United States (EOP). OMB’s most prominent function is to produce the President’s Budget, but OMB also measures the quality of agency programs, policies, and procedures to see if they comply with the president’s policies and coordinates inter-agency policy initiatives. OMB prepares the President’s budget proposal to Congress and supervises the administration of the executive branch agencies. OMB evaluates the effectiveness of agency programs, policies, and procedures, assesses competing funding demands among agencies, and sets funding priorities. OMB ensures that agency reports, rules, testimony, and proposed legislation are consistent with the president’s budget and with administration policies.

OMB also oversees and coordinates the administration’s procurement, financial management, information, and regulatory policies. In each of these areas, OMB’s role is to help improve administrative management, to develop better performance measures and coordinating mechanisms, and to reduce any unnecessary burdens on the public.

OMB’s critical missions are:

Budget development and execution is a prominent government-wide process managed from the Executive Office of the President (EOP) and a device by which a president implements his policies, priorities, and actions in everything from the Department of Defense to NASA.
OMB manages other agencies’ financials, paperwork, and IT.

Further reading –

https://en.wikipedia.org/wiki/Office_of_Management_and_Budget

A National Provider Identifier or NPI is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). The NPI has replaced the unique physician identification number (UPIN) as the required identifier for Medicare services, and is used by other payers, including commercial healthcare insurers. The transition to the NPI was mandated as part of the Administrative Simplifications portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and CMS began issuing NPIs in October 2006.[1] HIPAA covered entities such as providers completing electronic transactions, healthcare clearinghouses, and large health plans were required by regulation to use only the NPI to identify covered healthcare providers by May 23, 2007. CMS subsequently announced that as of May 23, 2008, CMS will not impose penalties on covered entities that deploy contingency plans to facilitate the compliance of their trading partners (e.g., those healthcare providers who bill them). The posted guidance document can be used by covered entities to design and implement a contingency plan. Details are contained in a CMS document entitled, “Guidance on Compliance with the HIPAA National Provider Identifier (NPI) Rule.” Small health plans have one additional year to comply.

All individual HIPAA covered healthcare providers (physicians, pharmacists, physician assistants, midwives, nurse practitioners, nurse anesthetists, dentists, denturists, chiropractors, clinical social workers, professional counselors, physical therapists, occupational therapists, pharmacy technicians, athletic trainers etc.) or organizations (hospitals, home health care agencies, nursing homes, residential treatment centers, group practices, laboratories, pharmacies, medical equipment companies, etc.) must obtain an NPI for use in all HIPAA standard transactions, even if a billing agency prepares the transaction. Once assigned, a provider’s NPI is permanent and remains with the provider regardless of job or location changes.

Other health industry workers, such as admissions and medical billing personnel, housekeeping staff, and orderlies, who provide support services but not health care, are not required to obtain the NPI.

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Further reading –

https://en.wikipedia.org/wiki/National_Provider_Identifier

National Plan and Provider Enumeration System –

The NPI is the standard for a unique identifier for health care providers for use in the health care system. NPPES is the application that health care providers must use to be awarded an NPI number.

Within the NPPES, there are two types of providers:
• Type 1 Providers – Health care providers who are individuals, including physicians, dentists, and all sole proprietors (An individual is eligible for only one NPI.)
• Type 2 providers – Health care providers who are organizations, including physician groups, hospitals, nursing homes, and the corporation formed when an individual incorporates him/herself.

Further reading –

https://nppes.cms.hhs.gov/webhelp/nppeshelp/NPPES%20FAQS.html#How-can-I-gain-access-to-my-Type-2-NPI