Transcript Reimbursement

Alyssa Trotsky, DPT
University of Michigan Hospital
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73% report they were not adequately prepared for
managed care and other reimbursement issues by
their professional education programs.
71% do not think they are well informed regarding
the government’s fraud and abuse investigations
31% are aware of situations where a PT was
encouraged to provide or document services in an
unethical, fraudulent, or illegal manner.
Pay Day
Patient
Billing
Treatment
Payment
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Acute Care: DRG
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Inpatient Rehab: PPS
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Skilled Nursing Facilities: PPS & RUG
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Home Health Care: PPS & OASIS
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Outpatient: Individual insurance & Caps
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DRG: diagnosis-related group
 Each case is classified into one of 467 groups
 Specified sum of money is provided to hospital
from insurance per patient diagnosis.
 Patients who are uninsured will need to provide
costs out of pocket.
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PPS: prospective payment system
 Cases are grouped into Rehabilitation Impairment
Categories
 Further grouped into case-mix groups (CMG)
 Then grouped into Tier 1-4 within each CMG
 Additional adjustments are made for interrupted
stays, short stays of less than 3 days, short-stay
transfers, and high cost outliers.
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PPS: prospective payment system
 RUG: resource utilization group
 creates tiers of payment based on level of
nursing care, room considerations, and
minutes of therapy provided
 assessment review dates (ARD)
 5 levels – based on number of hours of
therapy provided
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PPS: prospective payment system
 Home health agencies are paid a pre-determined rate.
 Health condition, care needs, and geographic location
are taken into consideration.
 Payment is for 60 day episodes
 Payment is based on case mix assignment
 Nurse or therapist uses the Outcome and Assessment
Information Set (OASIS) to assess patient condition.
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Reimbursement specific to insurance
“Therapy Caps” for patients with Medicare
Part B
 $1,900 for PT/SLP services in 2013
 $1,900 for OT services in 2013
 Manual Medical Review
 KX Modifier
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Medicare
Medicaid
BCBS
Cigna
Humana
Highmark
Workers’ Compensation
Automobile Insurance
Tricare & VA
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Part A & B
Qualifications:
a) >65 years
b) Under 65 with certain diagnoses
c) People with end stage renal disease
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8 Minute Rule:
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≥
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8 to < 23
23 to < 38
38 to < 53
53 to < 68
68 to < 83
83 to < 98
98 to < 113
113 to < 128
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unit
units
units
units
units
units
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units
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ICD-9 Code
Soon to be replaced by ICD-10 codes
 More specific
 Ex: ICD-9 – angioplasty
ICD-10 – dilation of right femoral artery with
drug-eluting intraluminal device, open approach
- dilation of right femoral artery with
intraluminal device, open approach
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G-Codes for patients with Medicare only in
July 2013
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Initial Evaluation (97001)
Aquatic Therapy (97598)
Orthotic Management and Training (97113)
Physical Performance Test and Report (97750)
Therapeutic Activities: any activity to imrpove
function including positioning, bed mobility, tilt
table, proper body mechanics in the performance
of ADL’s, and transfers.
Neuromuscular Re-Education: re-education of
movement, balance, coordination, kinesthetic
sense, posture, and proprioception.
Prosthetic Training
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Therapeutic Exercise: exercise to improve
breathing, endurance, oral-motor function,
posture, ROM, and/or strength,
stretching/flexibility exercises, and
neuromobilization.
Wheelchair Management
Community Re-Entry
Manual Therapy Techniques
Gait Training
Iontophoresis
Airway Clearance Techniques
Electrical Stimulation VS. Unattended Electrical
Stimulation
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Smart Billing!
Reimbursed different amounts for each
procedure
◦ Ex: Initial Evaluation ($224.00)
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Inpatient Rehab, Skilled Nursing Facility (Part
A), Acute Care:
o can bill separately for the distinct services provided
at the same time
o ensure co-treatment is clinically appropriate and
provided for the sole benefit of the patient
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Home Health Care:
o only one therapist could bill
o if both patients were treated same day but
separate times, then both therapists could bill
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Skilled Nursing Facility (Part B), Outpatient
Hospital and Physical Therapists in Private
Practice:
o Cannot each bill separately for the same service
o Cannot bill for different services provided at the
same time to the same patient
o When two therapists work together, you may split
the minutes for timed codes and each bill for part
of the treatment minutes, but you may not both bill
timed codes for the same minutes.
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Timeliness of care.
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Work with utilization management or case
management.
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Proper utilization of support personnel.
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Efficient use of resources: aware of costs
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What are the payment policies of payer?
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Documentation of skilled intervention.
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Explanation of Benefits (EOB)
Denials and appeals
Write offs
◦ Related to tax laws
Balance billing
◦ Provider requests more cost than what the health insurance
pays
First party pay
◦ Which insurance plan pays first
 Ex. Coordination of benefits
 In Michigan – Auto pays first, then private pay
Direct contracting
◦ Company cuts out the middle man of the insurance
company and draw up a contract to directly pay the health
care provider
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Patient: The name of the person who received the service. This may be you or one of your
dependents.
Insured ID Number: The identification number assigned to you by your insurance company.
This should match the number on your insurance card.
Claim Number: The number that identifies, or refers to the claim that either you or your health
provider submitted to the insurance company. Along with your insurance ID number, you will
need this claim number if you have any questions for your health plan.
Provider: The name of the provider who performed the services for you or your dependent.
This may be the name of a doctor, a laboratory, a hospital, or other healthcare provider.
Type of Service: A code and brief description of the health-related service you received from
the provider.
Date of Service: The beginning and end dates of the health-related service you received from
the provider. If the claim is for a doctor visit, the beginning and end dates will be the same.
Charge (also known as Billed Charges): The amount your provider billed your insurance
company for the service.
Not Covered Amount: The amount of money that your insurance company did not pay your
provider. Next to this amount you may see a code that gives the reason the doctor was not
paid a certain amount. A description of these codes are usually found at the bottom of the EOB,
on the back of your EOB or in a note attached to your EOB.
Total Patient Cost: The amount of money you owe as your share of the bill. This amount
depends on your health plan’s out-of-pocket requirements, such as an annual deductible,
copayments, and coinsurance. Also, you may have received a service that is not covered by
your health plan in which case you are responsible to pay the full amount.
Additional information may include the amount of payment actually made to your provider and
how much of your annual deductible has been met.
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Did you know your costs?
Can you be more efficient?
What are your outcomes relative to your
expenses?
Was your patient/client satisfied?
Did your patient/client meet his/her goals?
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Health Care System
Documentation – Justification/Reviews
Contract Negotiation
QI – Outcomes/Best Practice
Billables for PT
Basic Terms of Coding
Link to Ethics/Legal
Methods of Payment
Link to Core Values
History of Medicare/Workers Comp
Justification – Denials/Appeals
Advocacy – Political/Professional
Business for Revenues – Self Pay/POPTS
State Law
Risk Management
Healthcare for under insured – Pro Bono
Cost Benefit Ratio
Administration
Peer Review
Benefit Languages: Copay/ Deductibles
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APTA Courses
◦ Annual Conference
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Coding
Reversing Denied Claims
Wound Management Evidence for Reimbursement
Compliance for Medicare
◦ Reimbursement Seminar
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APTA Website
◦ CPT Coding Changes for 2005
◦ About Reimbursement
◦ Coding, Billing, and Payment Information about how PTs are
reimbursed: coding, billing, fees, costs, payment by treatment
setting
◦ Regulatory Issues: Medicare, HIPAA, and Others Medicare,
Medicare fee calculator, Medicaid, HIPAA, workers' compensation,
and state insurance commissions.
◦ References & Resources for Practice Positions on supervision,
legal and ethical issues, reimbursement resources, and
educational materials
◦ Information for Payers and Employers Payers frequently ask for
assistance with CPT coding, state practice acts, direct access,
CEUs, and APTA positions and policies - We provide help on these
pages. Payers can also sign up to attend one of our annual
Insurance Forums.
◦ Information for Consumers What you need to know about
physical therapy.
◦ Frequently Asked Questions
◦ Continuing Education APTA offers a variety of seminars, online
courses, and publications on reimbursement issues.
◦ Reimbursement Message Board
◦ Subscribe Now to Physical Therapy Reimbursement News
◦ Opinions Wanted
◦ "ASK REIMBURSEMENT"
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APTA Reimbursement News
◦ $79/yr
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Government Websites
◦ www.apta.org/govt_affairs/regulatory/medicare
◦ www.apta.org/govt_affairs/regulatory/fraud_abus
e
◦ www.apta.org/govt_affairs/regulatory/regulatory_document
ation
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Early - Knowledge
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Mid – Application
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End – Synthesis
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Professional Orientation
Professional Ethics in Health Care
Basic Exam Skills
HIPAA, Documentation, Priority of Interventions
◦ Preferred Practice Pattern Courses
◦ Clinical Education – 632 with exposure
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Management – Knowledge through Synthesis
Current Issues
Complex Clinical Problems
Clinical Education III
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Insurance Language/Definitions
Timelines of benefits
Cost of PT Services
Use of Support Personnel
CPT Codes and ICD9 and HCPCS
Billing Principles
Fee Schedules
Denials
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Cover services or supplies/equipment that
are medical necessary
◦ Services requiring the skills of a qualified provider
◦ Services are safe and effective
◦ Services are consistent with the symptoms or
diagnosis
◦ Services are accepted among the medical or
professional standards
◦ Services are the most appropriate, safe, and
effective
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Must provide support of the services or
supplies/equipment
What service or procedure was rendered
To what extent the service was rendered
Why the service, procedure, or other item was
medically necessary
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PT and OT are covered only for restorative
therapy by Medicare (expectation to restore a
patient’s level of function that has been lost
due to injury, disease, or illness (no
maintenance
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Services furnished could be furnished
elsewhere
Care that exceeds length of stay
Services denied or bundled
Physician standby services
Case management services (telephone calls
to/from the beneficiary)
Supplies included in the basic allowance of
the procedure
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Billing for services not furnished
Soliciting, offering or receiving a kickback, bribe or
rebate
Violating the physician self referral
Using an incorrect provider identifier
Selling, sharing or purchasing Medicare health
insurance claim numbers
Offering incentives to Medicare patients
Falsification of any documentation or billing
statement
Using inappropriate codes to get coverage
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Office of Inspector General (OIG)
Department of Justice (DOJ)
Federal Bureau of Investigation (FBI)
Medicare Administrative Contractors (MAC)
Recovery Audit Contractors (RAC)
Quality Improvement Organizations (QIO)
Program Safeguard Contractors (PSC)
Medicare Zone Program Integrity
Contractors (ZPIC)
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Coding and Documentation
◦ Establish continuing ed on CPT and ICD-9 coding
◦ Prepare a coding policy
◦ Document services and check documentation
◦ Arrange for outside consultant
Payer Correspondence
◦ Read all memos and newletters
◦ Keep all written correspondences
Claims Review
◦ Review and learn why claims are rejected
◦ If a mistake occurs, correct it immediately
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CPT Symbols
◦ Different symbols tell you code is new, revised, or
need an “add-on” code as it cannot stand alone (ex.
Hotpack needs something else with it)
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May use several CPT codes but each code
cannot exceed total time spent with patient
Documentation should match CPT code used
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http://www.cms.gov/manuals
Intro
Entitlement
Benefit Policy
Claims Processing
Secondary Payer Manual
Medicare Program Integrity Manual