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commercial insurance_Reimbursement Session II


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									Revenue and Reimbursement –
      Nuts and Bolts
          Presented by
     Linda Fabrizio Mazzoli
      MS, ATC, PTA, PES
     NATA District II COR
• To Provide some basic understanding on
  Revenue and Reimbursement Arenas
• Discuss Types of Services and Revenue
• Discuss Types of Reimbursement
• Review Third Party Reimbursement
         Objectives - Cont’d
• Outline some basic processes for third party
• Outline basic processes for reimbursement
• Give you resources to start your journey!
           Revenue Generation
•   Hospital - outpatient
•   Hospital - inpatient
•   Hospital - physician extender
•   College / secondary schools - Independent
•   College / secondary schools - union
• Physician extender
            Revenue Generation
•   Sole Proprietor - Outpatient Rehabilitation
•   Independent contractor
•   Industrial
•   Professional sports
•   DME / Protective bracing
•   Military
•   Consultant
• Know what services you are providing
  – PM&R, Prevention, Impact Testing, Fitness,
    Work Conditioning
• Clearly define your services
  – Taping vs. Prophylactic Strapping
  – Impact Testing or Neurocognitive Testing
• Clearly define your services associated with
  a payer.
ATs – Services that we provide as
  Diverse Healthcare Providers

 –   Education
 –   Risk Management
 –   Prevention Services
 –   Organization and Management Services
 –   Rehabilitation
 –   Injury Evaluation
 –   Event coverage
 –   Etc.
   Worth of Services = Revenue
• With a clear definition of services, comes a
  clear understanding of Worth.
• Fee Schedules
• Regional, National Rates
• Competitor Rates
Types of Reimbursement in those
•   CASH
•   Contract Rates
•   Case Rates
•   HSA
•   Self Pay
•   Third Party

Cash is KING!
• Contract Rates –
  –   School Contracts
  –   Educational Inservices
  –   Coding and Documentation Training
  –   Advisement of SOP Manual
  –   Teaching
• HealthCare Spending Accounts
  –   Newest wave of reimbursement
  –   More employers encouraging these accounts
  –   Discounts for employee participation
  –   Prevention is key service
• Case Rate
  – Rehabilitation of an ACL injury
  – Job Task Analysis
  – Documentation Audit
• Self Pay
  – Fitness evaluation
  – Rehabilitation
  – No different than cash

   Reimbursement is for everything
   Detailed process
   Documentation, documentation, documentation
   Market driven
   Politically driven
   Satisfying
   Professionally enhancing
• Third Party
  – Insurances
  – Poorest form of reimbursement to providers
  – Highest form of reimbursement from
     Third Party Reimbursement
•   Types of Insurance Plans
•   Contracting
•   Coding and Documentation
•   Billing Processes
•   Reimbursement
•   Appeals
       Types of Insurance Plans

   Service provider
   Indemnity payments
   Managed care
   Others
           Service Provider

 Blue Cross / Blue Shield
 Contracts directly with providers who are
  paid at agreed rates for covered services
 Operates independently in each state or
  region as state insurance codes allow
         Commercial Insurance
          & Indemnity Plans
              (Endangered Species)

   Reimbursement on fee-for-service basis
   Generally 80/20 split plus deductibles
   Out of pocket expenses are capped
   Includes major medical catastrophic amount
          Managed Care

   HMO
   EPO
   PPO
   POS
 Health Maintenance Organization
 Providers work for insurance company in its pure
  defined form
 States vary on how this entity is defined
 Patient must use network providers to have
  services covered
 Can create conflict of interest between the patient,
  provider and the payor
                 More HMO

   Patient pays copay
   No deductible
   Physician submits claims
   Provider paid according to set contract
    agreements or are actually on payroll with
    bonuses for cost containment
Exclusive Provider Organization

 Hybrid of HMO and PPO
 Providers not employed by payor, but
  limited, or closed panel, of payors
 Allows for patient to see only those on the
  list or panel
            EPO Continued

 Benefits and services paid for as agreed to
  in policy
 Provider has set limits of reimbursement per
 No benefits or reduced benefits (only 60%
  of cost paid or even less)
    Preferred Provider Organization
   Panels usually more open to providers
   Providers paid agreed upon rates
   Copay for patient, deductible varies
   Benefits reduced for seeing out of network
       Point of Service (POS)
 Pays providers of consumers choice
 Provider may have to agree to accept
  payments as if in network
 Patient may be responsible for balance
 Only restriction is ability to pay and
  services covered
 Similar to indemnity
Worker’s Compensation Insurance
 State mandated program for employees injured on
  the job
 Benefits include medical coverage and possibly
  lost wages depending on category
 Temporary Total Disability
 Permanent Partial Disability
 Permanent Total Disability
 Managed by commercial carrier or state operated
     CHAMPUS and Medicare
 Federal programs that do not recognize ATCs at
  this time
 Does not preclude ATC from treating those
  patients, just can’t bill for services
 Can work within the same facility
 May change as the military hires more ATCs in
  various settings
 Likely will take congressional action
Processes For Billing Third Party
•   Contracting Process
•   Credentialing Process
•   Billing Process
•   Collection Process
•   Appeals Process
      Third Party Contracting -
    Definitions of Reimbursement

•   Time Based
•   Fee For Service
•   Flat Rate
•   Case Rate
•   Capitation
  Contracting - Know the lingo
Hold Harmless   Gag Clause       Favored Nation

Exclusivity     Mandatory Time   Termination
                Limit/ Super

Quality         Contract         Evergreen
      Definitions within contract
• Time Based:
   Reimbursed a fixed amount based on time increments,
  regardless of the services/procedures provided
• Fee for Service:
  Reimbursed for each service/procedure provided
• Flat Rate:
  Reimbursed fixed amount per visit regardless of number
  of services/procedures provided or amount of treatment
  time rendered
    Definitions within contract
• Case Rate:
 Reimbursed a fixed amount per new patient
 case/episode of care
• Capitation:
 Reimbursed a pre-paid fixed amount for each
 person/member enrolled in the health plan regardless
 of services/procedures provided (PMPM rate)
    Third Party Reimbursement:
              Payer Fee Schedule
You should know:
•   Their fee schedule
•   Services/codes not reimbursed
•   Documentation and communication requirements
•   Requirements for documentation of charges
•   When to document & charge for re-evaluation
        Credentialing Process

 State regulations - + & -
 Essentials to being reimbursed
 Individual credentialing vs facility
 Carrier recognition of allied health provider
 Get to know the provider relations representative -
  know their process
 Detailed process - resume, CV, CEU, diploma
 May have to approach medical director of carrier
              Billing Process
•   Code Utilization
•   Fee Schedules
•   Claim Filing
•   Form Utilization
•   Time Frames
      Code Utilization - ICD-9

 ICD-9 CM – International Classification of
  Disease – Clinical Modifications
 Diagnostic codes for standardized formatting of
  describing diagnosis
 Indicate chronic, acute, disease, injury, condition
 Must match with appropriate CPT codes in billing

 Must be consistent with referring provider
 Differences can cause delays or even denial of
  claim being paid
 When initial, the vague or broad codes may be
  more appropriate
 Refer to ICD-9 and CPT code manuals
 Learned system, cheat sheets with most common
  are best
 Software available today for both
Code Utilization - HCPCS Codes

 HCPCS - Health Care Financing Administration
  Common Procedure Coding
 Healthcare’s Common Procedure Coding System,
  Levels I, II, III
 HCPCS II describe supplies, procedures and
  services not listed in CPT (e.g. “L” codes for
  orthotics and splinting)
 HCPCS III describe “local” codes (thru 1-1-03)
   Code Utilization - CPT Codes
• CPT Codes - Current procedural Terminology
   – Five-digit universal numerical code developed
     by the AMA to describe procedure or service
   – Physical Medicine and Rehabilitation -
     commonly used - 97000
 Well over 8,200 codes
 Provides uniform language
 Allows for reliable nationwide communication
          Why is CPT Used?

 To report MD/DO and other medical
  providers services under public/private
  health insurance programs
 Claims processing
 To develop guidelines for medical care
 Medical education & research
          97000 Series
Evaluation & Re-evaluation Codes

•   97001 – Physical Therapist Eval
•   97002 – Physical Therapist Re-Eval
•   97003 – Occupational Therapist Eval
•   97004 – Occupational Therapist Re-Eval
•   97005 – Athletic Trainer Eval
•   97006 – Athletic Trainer Re-Eval
           Code utilization

Use codes as they are defined
Use codes for services provided only
Use codes for the time spent providing the
 service only
Document/code for EVERY modality/procedure
             Billing Process

   HCFA 1500 - private setting
   UB - universal billing, hospital setting
   Most billing done electronically
   Fill fields properly
   Select correct codes
   Strive for “clean” claims
              HCFA 1500

 Form used for medical billing for Medicare,
  Medicaid, and commercial carriers (incl.
  worker’s compensation)
 Specific information in each field
 Codes for everything, not just CPT
 Can be done via various software for print
  or electronic submission
             Universal Billing

   UB forms
   Hospitals and clinics
   Mainly electronic
   Printed forms seldom used
   As in HCFA1500, fields filled in correctly
   Revenue code to designate type of provider
                Claim Filing
• Four important step for Filing A Claim
   – 1.   Good Documentation -
      •   “If it not written it is not done”
      •   SOAP note format
      •   Ensures quality work, outcomes and appropriateness
   – 2.   Preparation
      •   This is probably the most important step b/c must
          have a good working system
      Claim Filing - cont’d.
– 3. Review
    • In-House Audits or utilization review
        – Healthcare providers review documentation
          and coding to ensure: Improve documentation,
          standard terminology, assess appropriateness
          of the plan of care, and determine further
          necessity of treatment
– 4. Submission
    • Sending to the appropriate address or mail file
      Denial of Claim
        Common mistakes into 4 areas
• Appropriateness      • Compliance

• Completeness         • Timeliness
       Appealing Denied Claim
•   Review the Explanation of Benefits
•   Understand why you are not getting paid
•   Review third party payer guidelines
•   Talk with third party payers
•   Maintain a encounter sheet when talking to payers
•   Prepare a Cover letter
•   Show outcomes
• Theory of a better outcome
• Collecting evidence based standards of care
  – NORA
  – Research
• Patient Satisfaction
• Quality of Standards
• Showing Cost savings
 Comparison Cost Analysis of Rehabilitation Care
  Other Rehab providers vs. Athletic Therapist
Case study: A 24 y/o female patient reports to Physician with injured Left Ankle- Dx: Grade 3 Inversion sprain, care plan
     from MD indicates PWB as tolerated, taping for edema control, and referral for rehabilitation services indicating 3-
     4x/week for 4-6 weeks.

Initial Evaluation/Patient education       97001- PT provider                           97005- AT provider
Plan of care development        Care plan for 3x/week for 6 weeks                       4x/week for week 1 then
                                Care transferred to PTA                                 2-3x/week ATC providers

Blue Cross payment (BNE plan)               $57.92                                      $57.92

Week 1                       97140 Manual therapy                                       97140 Manual therapy
                             97014 Estim unattended                                     97014 Estim unattended
                             3 visits                                                   97110 Ther Exs
                                                                                        4 visits

BCBSMA BNE fee per visit       3 x $49.50 = $148.50                                     4 x $49.50 = $198.00

Week 2                  97140 Manual therapy                                            97110 Ther Ex
                        97014 Estim unattended                                          97112 Neuro Re-Ed
                        97110 Ther Exs                                                  97032 Estim Attended
                        3 visits                                                        3 visits
BCBSMA BNE fee per visit 3 x $49.50 = $148.50                                           3 x $49.50 = $148.50
Week 3                        Same as week #2                                              Same as week #2
                              3 visits                                                     Add 97530 Func training
                                                                                           3 visits
BCBSMA BNE fee per visit        3 x $49.50 = $148.50                                       3 x $49.50 = $148.50

Week 4                        97140 Manual therapy                                         97530 Func Training
                              97110 Ther Exs                                               97112 Neuro Re-ed
                              2 visits                                                     2 visits
                              97002 PT re-eval                                             97006 AT re-eval
                              1 visit                                                      1 visit
                              Continue RX progress to                                      DC from program- return to
                              Functional exercise and                                      MD for clearance to return to
                              Neuro re-training                                            play. Continue with HEP and
                              Return to MD for Status check                                instruction for patient to f/up
                                                                                           w/ AT for safe return to play
BCBSMA BNE fee per visit        3 visits x $49.50 = $148.50                                3 visits x $49.50 = $148.50

Week 5                   97530 Func Training                                               Total cost of service =
                         97112 Neuro Re-ed                                                 $701.42
BCBSMA BNE fee per visit 3 visits x $49.50 = $148.50

Week 6                          97530 Func Training
                                97112 Neuro Re-ed
BCBSMA BNE fee per visit                       3 visits x $49.50 = $148.50
     Pt. Discharged from PT with short-term goals met, no further education on return to participation status, or re-injury risk.
                                Total cost of service =                                     Total cost savings=
                                $948.42                                                     247.50
Note: In this example the real possibility of the patient re-injuring her ankle and needing additional therapy or surgical intervention is
     potentially greater with the other healthcare provider model. This factor alone could potentially inflate the pay out for BCBSMA
     to 3-5x the initial cost of care provided by the AT provider.
           ATCs are receiving
          reimbursement now!
•   Insurance Companies
•   Workers Comp.
•   The Blues
•   TPAs
•   CASH!
•   Many, Many More
        How Do you get Started
• What do you currently have in Place
  –   Athletic Training room standards of Care
  –   Documentation
  –   Policies and Procedures
  –   You probably already have everything
“Instead of thinking about where you are,
  think about where you want to be. It takes
  twenty years of hard work to become an
  overnight success.”
                                  Diana Rankin
“As you go through life, you find
 that if you don’t paddle your
 own canoe, you don’t move…”
                Katherine Hepburn
• Your State COR
• Gather your resources
  – Documentation programs
  – Pain Questionnaires
  – Insurance companies
• NATA Web Site
• Toolboxes being Developed

 Worker’s Comp: Key resources
 National Association of Insurance Commissioners
  (NAIC) 816-374-7259
 American Association of Health Plans (AHHP)
 Website clearinghouse for WC rules
 www.comp.state.nc.us/ncic/pagrs/wcadmdir.htm
          Resources Available

 Additional Resources
  •   ICD-9-CM AHA 312-422-3366
  •   HCPCS II HCFA 410-786-3000
  •   APTA: National Office APTA.org
  •    Fax on demand:1-703-531-0866
  •   APTA: Guide to PT Practice, coding manual
      published with St. Anthony’s (1-02)
           Resources Available

 Additional Resources
  •   The Center for Medicare Education
  •   http://www.MedicareED.org
  •   202-508-1210
  •   National information resource center for
      professionals and volunteers who provide
      consumer education about Medicare
• www.nata.org
• www.cms.hhs.gov/manuals/pm_trans/R179
           Resources Available

 More Websites:
  •   HCFA.gov/CMS.gov
  •   Local Medical Review Policies: LMRP.NET
  •   Ppsapta.org
  •   APTA.org
  •   PTManager.com
  •   Complianceinfo.com
  •   Compliance.com
  •   HIPAAdocs.com
             Resources Available
 RBRVS Resources
   • Medicare RBRVS: The Physician’s Guide 800-621-8335
   • Use of the Resource-Based Relative Value Scale (RBRVS)
     Beyond Medicare
   • Federal Register: November 1, 2000
      • New Orders, Superintendent of Documents
      • P.O. Box 371954
      • Pittsburgh, PA 15250-7954
      • 888-293-6498 (credit card) 202-512-2250 (fax)
      • APTA Department of Government Affairs
           Resources Available
 CPT Resources
   • AMA Department of Coding & Nomenclature 800-621-8335
   • AMA CPT Assistant Publication/Mastering the Reimbursement
   • APTA Guide to PT Practice, AOTA Practice Guidelines
   • APTA Department of Reimbursement, 800-999-2782, ext 8511
   • AOTA 800-877-1383
          Resource Lists
•   Websites
•   www.gopats.org
•   www.nata.org
•   www.cms.hhs.gov/medlearn
•   www.oig.hhs.gov
•   Any questions ?
            Resource Lists
• Reimbursement for Athletic Trainers by Marjorie J
  Albohm with Dan Campbell and Jeff G Konin To Order
  call 1-800-257-8290 or email at Orders@slackinc.com
• CPT Codebook; written by AMA and published by
  St.Anthony’s Publishing
• ICD-9 CM Codebook, published by St.Anthony’s
• Mastering the Reimbursement Process, Published by the
• Reimbursement manual 1 and 2 by the NATA

      Thank You!
   Linda Fabrizio Mazzoli
Cooper Bone and Joint Institute
   NATA District II COR
    PATS COR Co-Chair

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