Chapter 11 Reimbursement and Research Flashcards
Reimbursement:
-payment of funds by patient or insurer for PT services
1•Patient = 1st Party
2•Therapist/Provider = 2nd Party
3•Insurer = 3rd Party
•Capitation:
reimbursement method paying provider set fee each month (fixed fee) based on # of patients insured
•Fee for Service:
Payment for each service provided, norm used to be 100% bill paid, now only a % paid
•Managed care:
-Delivering healthcare services more inexpensively by controlling provision of benefits & services
1•Physicians, hospitals, etc contract with managed care company to accept a monthly $ to provide services to their plan participants
2•Participants are limited to those providers contracted
3•Clinical decisions influenced by administrative incentives & restraints
•Health maintenance organization (HMO)
1•Managed care organization who provides comprehensive medical care, especially preventive
2•Costs are managed by physician “gatekeepers” who dictate what services participants are allowed to have
•Preferred Provider Organization (PPO)
•Managed care organization that allows patients to obtain service on their own without “gatekeepers”, but they have to pay more if “out of network”
•National Provider Identification (NPI)-
Identifiers for healthcare providers (PTAs are listed under PT NPI)
•Prior authorization-
Requirement that patients get pre-approval prior to obtaining a healthcare service
•Eligibility-
Determination if person qualifies for insurance coverage
•Denial-
Refusal by insurer to reimburse for services
•Copay-
Amount of $ due each time managed care participants visit healthcare providers
Deductible:
Amount pt. has to pay before insurance $ kicks in
ICD-10:
-Refers to International Classification of Diseases
1•coding system for all diagnoses to be used in reimbursement
•CPT Current Procedural Terminology
1•5 number long codes used for nearly every healthcare service provided for billing purposes
2•Healthcare providers choose the billing code for every service provided
3•PT Provided services: typically listed in 97000 range
4•Timed code bill in 15’ increments = 1 unit, requires constant supervision
5•Falls under 8’ rule (Need 8’+ to bill/unit of service = 8-22’/unit)
6•97110 Therapeutic exercise, 97530 Ther.
Activities
7•97112 Neuromuscular re-education
•Untimed codes-
-1 unit of this code covers entire tx, does not require constant supervision, does not fall under 8’ rule
•97012 Mechanical Traction
•97014 Electrical Stimulation (unattended)
Medicare:
-largest provider of healthcare services in US, est. 1965 by Congress: Title IX
1•Covers age 65+, <65 with disabilities, Dx of end-stage renal disease (requires dialysis or kidney transplant)
2•Administered by Centers for Medicare & Medicaid (CMS)
Medicare
Has 4 Parts:
1.Part A: Hospital insurance (usually paid for from taxes during working years)
•Pays for hospitals, skilled nursing (not long term), hospice care, & HH
2.Part B: Medical insurance (requires paying a premium)
•Pays for doctors, outpatient visits, health services (PT included)
3.Part C: Medicare Advantage- health plans provided by private companies (with additional fees)
4.Part D: Medicare Prescription Drug Coverage (additional cost)
- Skilled Nursing Facility (SNF) Reimbursement
* Medicare using new payment system:
-Patient-Driven Payment Model (PDPM) and will base payment on what category of case mix they fall into (classifying them by characteristics)
Prospective Payment System (PPS)
•Fixed payment matched to diagnosis:
-related groups (DRG), used in inpatient rehab hospitals, skilled nursing facilities, home health, hospice, hospital outpatient departments, inpatient psychiatric services
•Moving away from Fee for Service to Quality Payment System
•Home Health New system:
Home Health Patient-Driven Groupings Model (PDGM)- also looks at pt. characteristics and places them in one of 432 case mix groups
Other Major Changes Dealing With Medicare
1•In 2018, Congress removed a therapy cap that limited Medicare patients to $2010/year in therapy services after many years of lobbying by the APTA
2•Services provided in outpatient clinics not associated with hospitals or SNFs are subject to the Quality Payment Program (QPP) that will reimburse based on outcome measures (better outcomes, better reimbursement)
3•Merit Based Incentive Payment System (MIPS)
4•Advanced Alternative Payment Models
Medicaid:
-State & Federal jointly funded healthcare program started in 1965 for children, non-elderly low income parents, pregnant women, non-elderly disabled, and low-income elderly people
1•CMS requires states to provide basic healthcare services for these populations
2•PT is considered an optional healthcare service & individual states determine if they will reimburse for it
3•Some states do not reimburse for PTA provided services
4•The Affordable Care Act required this program to extend services to all adults at or below 138% of poverty level
5•For Medicare and Medicaid details and up to date changes, refer to www.cms.gov
Private Insurers:
-provide healthcare reimbursement typically through employer provided plans
1•Examples include Blue-Cross, Humana, etc
2•Have a variety of plans that offer a variety of benefits, require copays, may require preauthorization
3•The Affordable Care Act (2010) was developed to help more people obtain health insurance/services in an affordable manner, but the outcome has been mixed.
•Workers Compensation:
-Insurance that employers are required to purchase from the state to cover worker injuries/Tx
HMOs: (Health Maintenance Organization)
-Form of managed care, restricts healthcare services to avoid excessive/inappropriate care ensuring favorable outcomes and contain expenses
1•Patients must see their gatekeeper- primary care physician (PCP) prior to being granted access to specialized services
2•Patients can only be treated by HMO physicians/services
3•Focuses on preventive health services to prevent illness
4•Healthcare providers receive a fixed fee for each participant in the program
5•Some patients feel that HMOs base important healthcare access decisions too much on $
6•PT may be limited or not reimbursed easily in this model
