3rd Party Payers Flashcards
Charity Care
Pro Bono - low income level, no insurance
Financial assistance programs
Self Pay
No insurance
Does not qualify for charity/pro bono
May need payment plan
Might get discount if pay cash in full at time of service
Explanation of Benefits
Something that says what was done with medical procedure, what the insurance covered, and the write off
Medically Necessary
Must be reasonable, evidence based, standard of care
Hospital based service
an “outpatient” facility but it is associated with a hospital
NPI - National Provider Identifier
All outpatient PTs need an NPI - a medicare number that sticks with you and goes on all of your claims
Write off - contractual
Contract with insurance company that says they will pay a certain amount
Say 80 of the 100 so write off is 20
Traditional type of insurance organization
Indemnity plans - commercial insurance companies
All organized under state laws
Act as insurers, not providers
Managed Care - type of insurance organization
HMO
PPO
POS
EPO
HMO
In network
Gatekeeper to control/coordinate care
PPO
Contract btw health plan and provider
Encouraged to use specific providers
Can go out of network
POS
Hybrid PPO/HMO
Like an open ended HMO
PCP required
Can go out of network
EPO
Cross between HMO and PPO
In network care
High deductible health plan (HDHP)
Preventative care covered, other expenses must be paid until deductible met
Can be paired with a health savings account (HSA insurance plans) - then you can carry over
Workers Compensation
State regulated - employee directs provider or employee choice
Case manager frequently involved
Communication/documentation required for continued approval
Medicare/Medicaid
CMS - Centers for medicare and medicaid services
Medicare - parts
A = hospital services B = outpatient services C = Medicare advantage plan D = outpatient prescriptions (private plans)
Tricare/Champus/VA
Health care program for uniformed service members, retirees, and their families
Military tx facilities vs civilian providers
Patient protection and affordable care act - Aims
Inc quality and affordability of health insurance
Lower uninsured rate
Contain rising costs
Patient protection and affordable care act - essential health benefits
9 essential health benefits
Patient protection and affordable care act - marketplaces
Providers qualified health plans (QHP) - 3 types - state based, partnership and federally facilitated
Qualified Health Plans
Cover the essential health benefits
Are modeled after states benchmark plan
Are subject to federal regulation and state insurance laws
Marketplace tips - Grace period
There is a grace period so it is important to check patient status
Adding a clause regarding nonpayment of health insurance premium to patient financial agreement is a good idea
Alternative payment methods
Accountable care organizations
Bundled payment models
Patient centered medical home
Accountable care organizations (ACOs)
Network of health care providers agree to be accountable for quality, cost and overall care of medicare beneficiaries
ACOs - meet quality standards in four key areas
Patient/caregiver experiences
Care coordination/patient safety
Preventative health
At risk population/frail elderly health
ACOs and PT
PTs can participate in an ACO but cannot create one
Bundled payment models
Bundled payment paid related to a treatment or conditions
Used to encourage coordination among providers and promote efficient care
Hospitals, physicians, and post acute care providers
Comprehensive Care for Joint Replacement - CJR
TKA, THA
Being tested for the next 5 years
Acute Care Episode - ACE
28 cardiac and 9 ortho inpatient surgical services and procedures jointly accountable for patient’s care
Patient Centered Medical Homes (PCMH)
Primary care practices provide and coordinate patients care
Community based health teams support primary care providers
Prevention, care management for patients with chronic conditions
Focus - managing care and directing medical care appropriately
Payment methods
Retrospective Payment Systems
Prospective Payment Systems
Pay for Performance
Retrospective Payment Systems
Fee for service/Fee schedule
Prospective Payment Systems
DRG RUG Per Diem Case Rate Capitation Multiple procedure payment
DRG
Diagnostic related group
Based on the diagnossi
RUG
Resource utilization group
Tiered payment depending on how patient presents and the service that may be needed
Per diem
per visit - set amount per patient per day
Case Rate
Per episode of care
Capitation
You are in agreement with insurance - you will get a set amount no matter what
Multiple procedure payment
scaled from private insurance
Pay for performance is based on
quality and outcomes of care
How are they covered? Acute Rehab
M, A, P
How are they covered? Acute Care
M, A, B, P
How are they covered? Pediatrics
M, P
How are they covered? SNF
M, A, B, P
How are they covered? OPT
M, B, P
How are they covered? Home care
M, A, B, P
Acute Care Hospital
Per Diem - private insurance
FFS - fee for service
Inpatient prospective payment system - DRG
Med part A
Acute rehab/Rehab hospital/Inpatient Rehab Facility
Per Diem - private insurance
IRF PPS (prospective payment system)
Medicare - newer than DRG but same principle
IRF PAI (need to fill out)
3 hour rule - 3 hrs of therapy 5 days a week
SNF
Per Diem - private insurance
Case Mix - PPS - Med A
Minimum Data set (MDS)
RUGs - 5 levels (low to ultra high)
NH
Out of pocket
Medicaid
Home Health
PPS for medicare - need to fill out OASIS Must track minutes of PT Quality reporting Med B Private insurance
Outpatient Care
Third party payment - FFS, per visit, Case rate, Cpaitation, Med B, Work comp, employer contract/on site
First party payment - self pay
Medicare physician fee schedule - Resource based relative value scale
Based on difficulty of work, practice expense, and malpractice expense
Schools
Provide services unter the individuals with disabiliteis in education act and the elementary and secondary education act
Medicaid/childrens health insurance program - fed and state but state administers
Upcoding
Charging for more complex service
Unbundling
Billing separately for procedures that are covered by one fee
Examples of fraud
Upcoding, Unbundling
Charging for services not provided
Double billing
Lack of medical necessity
Diagnosis determines reimbursement?
DRG
Acute Care
Paid for each service that is provided?
Outpatient
Fee for service
Accept negotiated rate for services for an episode of care?
Case rate, ACO, bundle payment
Outpatient or ACO
Payment based on patient classification which is tiered according to minutes?
RUG
SNF
Receive guaranteed monthly lump sum
Capitation
Outpatient
