Revenue and Reimbursement Nuts and Bolts

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Revenue and Reimbursement Nuts and Bolts

• Presented by
• Linda Fabrizio Mazzoli
• MS, ATC, PTA, PES
• NATA District II COR

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Objectives

• To Provide some basic understanding on Revenue
  and Reimbursement Arenas
• Discuss Types of Services and Revenue
  Opportunities
• Discuss Types of Reimbursement
• Review Third Party Reimbursement opportunities

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Objectives - Contd

• Outline some basic processes for third party
  reimbursement
• Outline basic processes for reimbursement denial
• Give you resources to start your journey!

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Revenue Generation Opportunities

• Hospital - outpatient
• Hospital - inpatient
• Hospital - physician extender
• College / secondary schools - Independent
• College / secondary schools - union
• Physician extender

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Revenue Generation Opportunities

• Sole Proprietor - Outpatient Rehabilitation
• Independent contractor
• Industrial
• Professional sports
• DME / Protective bracing
• Military
• Consultant

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Services

• Know what services you are providing
• PMR, 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.

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ATs Services that we provide as Diverse
Healthcare Providers

• Education
• Risk Management
• Prevention Services
• Organization and Management Services
• Rehabilitation
• Injury Evaluation
• Event coverage
• Etc.

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Worth of Services Revenue

• With a clear definition of services, comes a
  clear understanding of Worth.
• Fee Schedules
• Regional, National Rates
• Competitor Rates

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Types of Reimbursement in those opportunities

• CASH
• Contract Rates
• Case Rates
• HSA
• Self Pay
• Third Party

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Reimbursement

• Cash is KING!

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Reimbursement

• Contract Rates
• School Contracts
• Educational Inservices
• Coding and Documentation Training
• Advisement of SOP Manual
• Teaching

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Reimbursement

• HealthCare Spending Accounts
• Newest wave of reimbursement
• More employers encouraging these accounts
• Discounts for employee participation
• Prevention is key service

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Reimbursement

• Case Rate
• Rehabilitation of an ACL injury
• Job Task Analysis
• Documentation Audit
• Self Pay
• Fitness evaluation
• Rehabilitation
• No different than cash

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Reimbursement

• THIRD PARTY
• Reimbursement is for everything
• Detailed process
• Documentation, documentation, documentation
• Market driven
• Politically driven
• Satisfying
• Professionally enhancing

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Reimbursement

• Third Party
• Insurances
• Poorest form of reimbursement to providers
• Highest form of reimbursement from consumers

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Third Party Reimbursement

• Types of Insurance Plans
• Contracting
• Coding and Documentation
• Billing Processes
• Reimbursement
• Appeals

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Types of Insurance Plans

• Service provider
• Indemnity payments
• Managed care
• Others

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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

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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

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Managed Care

• HMO
• EPO
• PPO
• POS

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HMO

• 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

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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

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Exclusive Provider Organization

• EPO
• 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

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EPO Continued

• Benefits and services paid for as agreed to in
  policy
• Provider has set limits of reimbursement per
  contract
• No benefits or reduced benefits (only 60 of cost
  paid or even less)

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Preferred Provider Organization(PPO)

• Panels usually more open to providers
• Providers paid agreed upon rates
• Copay for patient, deductible varies
• Benefits reduced for seeing out of network
  provider

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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

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Workers 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

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CHAMPUS and Medicare

• Federal programs that do not recognize ATCs at
  this time
• Does not preclude ATC from treating those
  patients, just cant 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

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Processes For Billing Third Party Insurances

• Contracting Process
• Credentialing Process
• Billing Process
• Collection Process
• Appeals Process

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Third Party Contracting - Definitions of
Reimbursement

• Time Based
• Fee For Service
• Flat Rate
• Case Rate
• Capitation

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Contracting - Know the lingo
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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

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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)

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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

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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

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Billing Process

• Code Utilization
• Fee Schedules
• Claim Filing
• Form Utilization
• Time Frames

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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
  process

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ICD-9

• 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

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Code Utilization - HCPCS Codes

• HCPCS - Health Care Financing Administration
  Common Procedure Coding
• Healthcares 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)

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Code Utilization - CPT Codes

• CPT Codes - Current procedural Terminology Codes
• Five-digit universal numerical code developed by
  the AMA to describe procedure or service provided
  
• Physical Medicine and Rehabilitation - commonly
  used - 97000
• Well over 8,200 codes
• Provides uniform language
• Allows for reliable nationwide communication

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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 review
• Medical education research

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97000 SeriesEvaluation 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

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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
  provided

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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

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HCFA 1500

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

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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

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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

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Claim Filing - contd.

• 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
  electronically.

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Denial of ClaimCommon mistakes into 4 areas

• Appropriateness
• Completeness

• Compliance
• Timeliness

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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

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Outcomes

• Theory of a better outcome
• Collecting evidence based standards of care
• NORA
• Research
• Patient Satisfaction
• Quality of Standards
• Showing Cost savings

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ATCs are receiving reimbursement now!

• Insurance Companies
• Workers Comp.
• The Blues
• TPAs
• CASH!
• Many, Many More

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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

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• 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

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• As you go through life, you find that if you
  dont paddle your own canoe, you dont move
• Katherine Hepburn

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Resources

• Your State COR
• Gather your resources
• Documentation programs
• Pain Questionnaires
• Insurance companies
• NATA Web Site
• Toolboxes being Developed

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Resources

• Workers Comp Key resources
• National Association of Insurance Commissioners
  (NAIC) 816-374-7259
• American Association of Health Plans (AHHP)
  www.aahp.org
• Website clearinghouse for WC rules
  www.dol.gov/dol/esa/public/owcp_org.htm
• www.comp.state.nc.us/ncic/pagrs/wcadmdir.htm

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Resources Available

• Additional Resources
• ICD-9-CM AHA 312-422-3366
• HCPCS II HCFA 410-786-3000
• APTA National Office APTA.org
• Fax on demand1-703-531-0866
• APTA Guide to PT Practice, coding manual
  published with St. Anthonys (1-02)

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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

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Resources

• www.nata.org
• www.cms.hhs.gov/manuals/pm_trans/R1793B3.pdf

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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

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Resources Available

• RBRVS Resources
• Medicare RBRVS The Physicians 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

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Resources Available

• CPT Resources
• AMA Department of Coding Nomenclature
  800-621-8335
• AMA CPT Assistant Publication/Mastering the
  Reimbursement Process
• APTA Guide to PT Practice, AOTA Practice
  Guidelines
• APTA Department of Reimbursement, 800-999-2782,
  ext 8511
• AOTA 800-877-1383

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Resource Lists

• Websites
• www.gopats.org
• www.nata.org
• www.cms.hhs.gov/medlearn
• www.oig.hhs.gov
• Any questions ?

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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_at_slackinc.com
• CPT Codebook written by AMA and published by
  St.Anthonys Publishing
• ICD-9 CM Codebook, published by St.Anthonys
  Publishing
• Mastering the Reimbursement Process, Published by
  the AMA
• Reimbursement manual 1 and 2 by the NATA

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QUESTIONS

• ?????

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Thank You!

• Linda Fabrizio Mazzoli
• MS,ATC, PTA, PES
• Cooper Bone and Joint Institute
• 856-912-0416
• NATA District II COR
• PATS COR Co-Chair