Reimbursement

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Reimbursement

• Alyssa Trotsky, DPT
• University of Michigan Hospital

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APTA Member SurveySummer, 2000

• 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 governments 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.

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Where Does Reimbursement Fit?
Pay Day
Patient
Billing
Treatment
Payment
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Reimbursement Across The Continuum Of Care

• Acute Care DRG
• Inpatient Rehab PPS
• Skilled Nursing Facilities PPS RUG
• Home Health Care PPS OASIS
• Outpatient Individual insurance Caps

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Acute Care Reimbursement

• 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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Inpatient Rehabilitation Reimbursement

• 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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Skilled Nursing Facility Reimbursement

• 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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Home Health Care Reimbursement

• 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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Outpatient Physical Therapy Reimbursement

• 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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Common Insurances

• Medicare
• Medicaid
• BCBS
• Cigna
• Humana
• Highmark
• Workers Compensation
• Automobile Insurance
• Tricare VA

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Medicare

• Part A B
• Qualifications
• gt65 years
• Under 65 with certain diagnoses
• People with end stage renal disease

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Billing

• 8 Minute Rule
• 8 to lt 23 1 unit
• 23 to lt 38 2 units
• 38 to lt 53 3 units
• 53 to lt 68 4 units
• 68 to lt 83 5 units
• 83 to lt 98 6 units
• 98 to lt 113 7 units
• 113 to lt 128 8 units

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Billing In Outpatient Setting

• 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
• G-Codes for patients with Medicare only in July
  2013

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Types of Charges

• 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 ADLs, and transfers.
• Neuromuscular Re-Education re-education of
  movement, balance, coordination, kinesthetic
  sense, posture, and proprioception.
• Prosthetic Training

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Types of Charges

• Therapeutic Exercise exercise to improve
  breathing, endurance, oral-motor function,
  posture, ROM, and/or strength, stretching/flexibil
  ity 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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Relative Value Units (RVUs)

• Smart Billing!
• Reimbursed different amounts for each procedure
• Ex Initial Evaluation (224.00)

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Co-Treatment Requirements Under Medicare

• Inpatient Rehab, Skilled Nursing Facility (Part
  A), Acute Care
• can bill separately for the distinct services
  provided at the same time
• ensure co-treatment is clinically appropriate
  and provided for the sole benefit of the patient
• Home Health Care
• only one therapist could bill
• if both patients were treated same day but
  separate times, then both therapists could bill

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Co-Treatment Requirements Under Medicare

• Skilled Nursing Facility (Part B), Outpatient
  Hospital and Physical Therapists in Private
  Practice
• Cannot each bill separately for the same
  service
• Cannot bill for different services provided at
  the same time to the same patient
• 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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Providing Treatment

• Timeliness of care.
• Work with utilization management or case
  management.
• Proper utilization of support personnel.
• Efficient use of resources aware of costs
• What are the payment policies of payer?
• Documentation of skilled intervention.

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Payment

• 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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Explanation of Benefits

• 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 plans 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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Pay Day

• 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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What Students Must Learn

• 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

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Resources

• APTA Courses
• Annual Conference
• Coding
• Reversing Denied Claims
• Wound Management Evidence for Reimbursement
• Compliance for Medicare
• Reimbursement Seminar

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Resources

• 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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Resources

• APTA Reimbursement News
• 79/yr
• Government Websites
• www.apta.org/govt_affairs/regulatory/medicare
• www.apta.org/govt_affairs/regulatory/fraud_abuse
• www.apta.org/govt_affairs/regulatory/regulatory_do
  cumentation

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Where in the Curriculum?

• Early - Knowledge
• Professional Orientation
• Professional Ethics in Health Care
• Basic Exam Skills
• HIPAA, Documentation, Priority of Interventions
• Mid Application
• Preferred Practice Pattern Courses
• Clinical Education 632 with exposure
• End Synthesis
• Management Knowledge through Synthesis
• Current Issues
• Complex Clinical Problems
• Clinical Education III

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Major Themes

• 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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Coverage

• 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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Documentation

• 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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Physical Therapy

• PT and OT are covered only for restorative
  therapy by Medicare (expectation to restore a
  patients level of function that has been lost
  due to injury, disease, or illness (no maintenance

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Services Not Medically Necessary

• 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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Examples of Fraud or Abuse

• 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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Regulatory Agencies

• 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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Action Plans

• 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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Procedure Codes

• 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)
• 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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Online CSM Manual System

• http//www.cms.gov/manuals
• Intro
• Entitlement
• Benefit Policy
• Claims Processing
• Secondary Payer Manual
• Medicare Program Integrity Manual