Health Insurance and Billing

Question 1

What are independent health insurance companies?

Answer 1

-reimbursement is either fee for service or managed care
-examples: Cigna, HMO, PPO

Question 2

what are private health insurance companies?

Answer 2

-reimbursement is usually fee for service
-examples: BCBS, Aetna, UHC

Question 3

What are the government health insurances?

Answer 3

-medicare, medicaid, and workers compensation

Question 4

What is fee for service?

Answer 4

-traditional payment model
-physician/healthcare providers determine the actions to be taken and insurance companies pay part of the fee
-physicians/healthcare providers are paid based on the number of treatment/services provided
-with fee for service, patients can go see any physician they want, including most specialists
-after paying a yearly deductible, the patients usually have a co-payment (80%/20%)

Question 5

what is managed care?

Answer 5

-contain specific built-in cost controls
-managed care reduces costs by limiting choices
-managed care has contracts with healthcare providers to provide services at a reduced cost

Question 6

Who uses Medicaid?

Answer 6

-individuals with limited income and resources, and those with disabilities
-it is jointly funded through the federal and state governments
-covers both inpatient and outpatient, diagnostic testing, home health care and more

Question 7

Who uses Medicare?

Answer 7

-federal health insurance
-65 or older
-certain people under 65 with disabilities
-people at any age with end stage renal disease

Question 8

What is Medicare Part A used for?

Answer 8

hospital insurance

Question 9

What is Medicare Part B used for?

Answer 9

medical insurance -PT, doctors office visits, x-rays, screenings

Question 10

What is Medicare Part C used for?

Answer 10

medicare advantage plans

Question 11

What is Medicare Part D used for?

Answer 11

prescription drug coverage

Question 12

Which medicare if services exceed the annual threshold amount, PT claims must include what?

Answer 12

KX modifier- a confirmation that the services are medically necessary as justified by the documentation in the medical record

Question 13

Which part of medicare is an automatic enrollment and funded through payroll taxes?

Answer 13

Medicare Part A

Question 14

What is the threshold as of 2024 for the calendar year with medicare?

Answer 14

$2,330 -after meeting the threshold the KX modifier is important for documentation

Question 15

The Balance Budget Act requires all claims for Outpatient Services be reported using a uniform coding system and required payment under a prospective payment system called?

Answer 15

Medicare Physician Fee Schedule (MPFS)

Question 16

MPFS medicare percentages

Answer 16

-medicare pays 80%
-coinsurance payment is made at 20% of allowable

Question 17

What are CPT codes?

Answer 17

-current procedural terminology codes
-used to describe interventions provided to a patient
- most commonly fall into two categories: untimed (service based) and timed

Question 18

What is untimed CPT codes?

Answer 18

-only bill for one unit per visit regardless of how much time was spent performing the intervention or number of body parts treated

Question 19

What are timed based codes?

Answer 19

-billed based on the amount of time spent performing the intervention, usually based on 15 min increments
-utilize 8 min rule

Question 20

Who follows the 8 minute rule?

Answer 20

-medicare, medicaid, tricare, CHAMPUS
-additionally many other commercial insurance plans

Question 21

8 minute rule quick reference

Answer 21

1 unit: 8-22
2 unit: 23-37
3 unit: 38-52
4 unit: 53-67
5 unit: 68- 82

Question 22

When is the CQ modifier applied?

Answer 22

When PT services furnished in whole by a PTA or in part by PTA