life science fast track - reimbursement
DESCRIPTION
Are you building on an exisiting code? Do you have new technology for an old device? Where does your company sit in the revenue cycle? Is there a code for the thing you have, what you do, and what you do with it? Your emerging company strategy is informed by regional codes and you need to understand where you fit on the reimbursement continuum. Get all your questions answered in this session.TRANSCRIPT
Q: WHAT’S YOUR BIOTECHNOLOGY WORTH?
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A: Whatever providers get paid for it
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Two Jobs
Keep ‘em out of the Poor House House Keep ‘em out of the Big House House
When do you need a reimbursement strategy?
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A system of carrots & sticks
Does your technology help the provider play offense or defense?
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Codes
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Types of Codes
What we do
Why we do it
What we do it with
Who did it
Where we did it on the patient
Where we did it in the building
If it went right, wrong, easy, hard or incomplete
If we did it and we didn’t mean to
If we did it again
If we did it and we knew we shouldn’t have
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CONFIDENTIAL
Existing Code or New Code?
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Current Procedural Terminology (CPT) – AMA– Physicians– Hospitals– Labs– Imaging Centers
Healthcare Common Procedural Coding System (HCPCS) - CMS-– Hospitals– Physicians– Pharmacy– DME– Home Health– Post Acute Skilled Nursing
Common Dental Terminology (CDT) - ADA– Dental, Orthodontia and Oralmaxiofacial
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Criteria for new codes
FDA approved
No existing code describes it in whole or in part: “significant therapeutic distinction”
Volume criteria: 3% of affected population - it’s not extraordinary and unusual and rare – we have unlisted codes for that.
Category I vs. Category III “5-year trial codes”
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How does a price get assigned to a code?
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How Doctors are Paid
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How Hospitals are Paid two ways
“IN-Patients” “OUT-Patients”
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Hospital Reimbursement Appendectomy
IN-Patient
$6,300
Out-Patient
$3,650
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Hey! I’m paid $600 and don’t
care
How Skilled & Residential Nursing Homes are Paid
Fixed Price Agreement (SNF PPS) Per Diem
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How Home Health Agencies are Paid
Skilled Svs - Fixed Price for 60d (HHA PPS)Skilled Svs – Per Visit Non-Skilled Per Visit
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How Hospice is Paid
Per Diem – All In – And even after death
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Impact of Coverage Determination Policies
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And we have to change everything
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Why is this a New Era?
We can’t afford the current state
We’re not sure what to do about it
We have to change everything about the way we move information & money in healthcare
Eric Topol says we won’t need doctors if our iphonesget good enough
Health Shortage
In the system, the only thing less profitable than health…………………….
is sudden death.
Impact of PPACA (Obama Care)
Innovations in Payment Systems
– Consolidated or Bundled Payments• Physicians
• Hospitals
• Post Acute Providers
– Pay for Performance & Requirement of EMR
– Limited Networks – Creation of Scarcity of Providers
– Uniform datasets
– Health data banks (demonstration project in Ohio)
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Impact of PPACA – Cost Shifting
ACOs and ACEs
Unprecedented Burden to Practice Medicine – Who Will be Left Standing?
Physician Shortage
ICD-10
Yet in the face of health care spending that is unrivaled anywhere else in the world, while we’re drowning in disease, what the system is demanding of our doctors…….
is a better description of the water.
Questions?
Disclaimers
ICD-9-CM NoticeThe International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is published by the United States Government. A CD-ROM, which may be purchased through the Government Printing Office, is the only official Federal government version of the ICD-9-CM. ICD-9-CM is an official Health Insurance Portability and Accountability Act standard.
CPT Disclaimer -- American Medical Association (AMA) Notice and DisclaimerCPT codes, descriptions and other data only are copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
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Contact Information
Maria Shinn Bouck, CPC, CPMA, CHC
Director, SS&G Healthcare
1422 Euclid Ave Suite 1500
Cleveland, Ohio 44115
Direct: 216.325.1739
Fx: 888.972.4917
Mobile: 440.829.9800
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