revenue and reimbursement – nuts and bolts presented by linda fabrizio mazzoli ms, atc, pta, pes...
TRANSCRIPT
Revenue and Reimbursement – Nuts and Bolts
Presented by
Linda Fabrizio Mazzoli
MS, ATC, PTA, PES
NATA District II COR
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
Objectives - Cont’d
• Outline some basic processes for third party reimbursement
• Outline basic processes for reimbursement denial
• Give you resources to start your journey!
Revenue Generation Opportunities
• Hospital - outpatient • Hospital - inpatient • Hospital - physician extender • College / secondary schools - Independent• College / secondary schools - union
• Physician extender
Revenue Generation Opportunities
• Sole Proprietor - Outpatient Rehabilitation• Independent contractor• Industrial• Professional sports• DME / Protective bracing• Military• Consultant
Services
• 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 opportunities
• CASH
• Contract Rates
• Case Rates
• HSA
• Self Pay
• Third Party
Reimbursement
Cash is KING!
Reimbursement
• Contract Rates – – School Contracts – Educational Inservices– Coding and Documentation Training– Advisement of SOP Manual – Teaching
Reimbursement
• HealthCare Spending Accounts– Newest wave of reimbursement– More employers encouraging these accounts– Discounts for employee participation– Prevention is key service
Reimbursement
• Case Rate– Rehabilitation of an ACL injury– Job Task Analysis– Documentation Audit
• Self Pay– Fitness evaluation– Rehabilitation– No different than cash
Reimbursement
THIRD PARTY Reimbursement is for everything Detailed process Documentation, documentation, documentation Market driven Politically driven Satisfying Professionally enhancing
Reimbursement
• Third Party– Insurances– Poorest form of reimbursement to providers– Highest form of reimbursement from
consumers
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
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
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
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
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)
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
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 Insurances
• 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
EvergreenContract Renegotiation
Quality
TerminationMandatory Time Limit/ Super session
Exclusivity
Favored NationGag ClauseHold Harmless
• 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)
Definitions within contract
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
process
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
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 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
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
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
Code utilization
Use codes as they are definedUse codes for services provided onlyUse codes for the time spent providing the
service only Document/code for EVERY modality/procedure
provided
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 electronically.
Denial of ClaimCommon mistakes into 4 areas
• Appropriateness
• Completeness
• Compliance
• 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
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 CareOther 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 therapy97014 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
Resources
• Your State COR
• Gather your resources– Documentation programs– Pain Questionnaires– Insurance companies
• NATA Web Site
• Toolboxes being Developed
Resources
Worker’s 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
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
Resources• www.nata.org• www.cms.hhs.gov/manuals/pm_trans/
R1793B3.pdf
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
Process• 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 [email protected]
• CPT Codebook; written by AMA and published by St.Anthony’s Publishing
• ICD-9 CM Codebook, published by St.Anthony’s Publishing
• Mastering the Reimbursement Process, Published by the AMA
• Reimbursement manual 1 and 2 by the NATA
QUESTIONS
?????
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