Reimbursement Flashcards
How do OTs get paid?
Reimbursement: monies from Patient Visits or Charges
Contracts to provide services elsewhere
Sales (equipment sales)
Tuition received for Continuing Education Offerings
Why do we need to know about reimbursement
Customer Satisfaction
Prevent Claim Denials
Accurate documentation of services
Prevent Fraudulent Claims
Job Security
Security of Our Profession
Established NPI
National Provider Identifier- 10-digit number
Identifies the practitioner who provided service
Get once start working
(connected to specific place of work)
Electronic Health Care transaction and code sets
standard coding for documenting billing and diagnostic information
What are the most common insurance?
Medicare and medicaid, employee funded and worker’s comp
Tricare is for
active duty military
IDEA
education mandate through education system
Deductible:
monies client pays out of pocket prior to being eligible for insurance coverage
Co-payment: aka co-pay:
set amount client pays for each visit
Co-insurance:
percentage client pays for services (often 20%)
Medicare
Elderly or Disabled
Funding by federal government
Participants pay premium
PPS (prospective payment system) with retrospective review
Medicaid
Indigent or Catastrophic
Funding Shared by state and federal
(state administers)
Low fee for service
Some providers refuse to accept or are not authorized to accept
Who can get medicare A
Hospital insurance program
inpatient rehab
inpatient services
hospice
psychiatric hospital
skilled nursing facility inpatient
skilled home health
What does Medicare Part B cover
Outpatient services
-Dr. and specialist
Doctor & specialist visits
Outpatient OT, PT, nutrition, psychology, etc
Outpatient testing
What does Medicare Part C cover
Managed Care Plan provided through private insurance (may charge additional premium)
Patient pays premium: covers A & B
may provide other benefits: dental, vision…
Medicare part D can cover
Prescriptions
What is the NY standard for medicaid
NY State eligibility (compared to Florida)
Individual: in NY eligible if income less than $18,755/year
Note: Federal Poverty Guide
1 person = $13,590 4 person =$27,750
Child Health Plus
NY Program to insure children
Aimed at those above Medicaid level
Individual making below $58,320 (maximum income level) can get insurance for their children at a reduced sliding scale cost
What are the mandatory services covered by Medicaid
Mandatory services covered
i.e., Hospitalization & SNF including OT, lab, x-ray
How does Medicaid pay
Number of visits, time period or types of conditions eligible, where provided (only at hospital outpatient)
PACE - Program for all-inclusive care for the elderly
For individuals who are eligible for both Medicare and Medicaid.
Program agrees to provide all health care services to that individual for an annual fee
From Doctors visits to hospitalizations to nursing home admissions to home health in exchange for a monthly rate from both Medicare and Medicaid.
PACE locally: Schenectady
Private Health Insurance
Employer funded or ACA purchased from Marketplace
Under 65-years-old mainly
Every company is different, but often follow Medicare’s recommendations and standards
What service of Medicare is this?
Substance abuse inpatient
Med A
What service of Medicare is this?
surgery for hip replacement?
Med A
What service of Medicare is this?
hospice care at home
Med A
What service of Medicare is this?
Skilled Nursing Home inpatient due to need for ventilator
Med A
What service of Medicare is this?
psyciatric hospitalization due to suicide attempt
Med A
What service of Medicare is this?
Substance abuse inpatient
Med A
What service of Medicare is this?
Hospice care at home
Med A
What service of Medicare is this?
outpatient hand
B
What service of Medicare is this?
outpatient substance clinic
B
What service of Medicare is this?
Dr. Office visit for upper resp infection
B
What service of Medicare is this?
Copay made as an MVP patient for outpatient therapy for a medicare patient MVP
C
What service of Medicare is this?
any services offered through CDPHP as a Medicare pt
C
What service of Medicare is this?
prescription for lydex for use in outpatient therapt with ultrasound
D
Outpatient OT services get paid by
Often a set fee negotiated with billing department for insurance company to pay
What kind of copay does a pt pay for OT?
specialist
Federal Employees Health and Benefit Program (FEHBP)
Services provided to active and retired federal employees
National model for health care reform
Administered in 350 different plans
Despite minimal coverage laws many have significant OT visit limits that are often combined with other therapies
Department of defense healthcare
TRICARE Programs
For active duty military & family
Services mostly provided at military health care facility and paid in full
Veterans Program
For honorably discharged military
Services can be provided outside of a VA facility, but may incur greater cost to the individual
Individuals with Disability Education Act (1980 & 1997)
Requires funding of services from the state and local funds including school taxes to provide:
free and appropriate education, which emphasizes special education and related services to meet individual needs
Worker’s comp
Insurance for the worker injured ON the job
Includes:
Wage replacement benefits
Medical treatment
Vocational rehabilitation
Financed by individual employers and state
Outpatient Worker’s comp
Treatment must be focused on
Restoring function (goal: RTW within 6 months)
Focus on active, not passive type therapy
Must re-evaluate 2-3 weeks after 1st visit and 3-4 weeks there after. Max 8 weeks without variance request.
Worker’s comp MTG = Medical Treatment
Guidelines
Established for shoulder, back, knee, and Carpal Tunnel
Other areas require prior approval
No Fault
Medical coverage related to a Motor Vehicle Accident
No copay, generous coverage
Outpatient OT and No Fault
Case manager may attend therapy session:
checking in to assure services are reasonable and the patient is progressing
Verify by calling to see that client is
“No Fault” eligible
Uninsured
Majority are: Young, white men (with Hispanic population following), without a college diploma, who work full time in retail or wholesale trades for low wages
Percentage of working age adults uninsured
2009:
2014:
2022:
21%
13%
8%
Billing can be based on:
Based on a formula of minutes provided or severity of patient diagnosis/condition
or
Flat rate for all rehab services in a given day (OT, PT, SLP)
Common Procedural Terminology (CPT) Code
National based codes for treatments
What is required to bill
ICD-10
ICD-10 codes are
diagnosis codes
International Classification of Diseases
Standard language created by
WHO
Used in billing to describe patient’s condition
ICD-10
Code used to describe condition
ICD-10
Code used to describe a procedure (often surgical)
G-Codes
Fee Schedule:
Our list of how much we hope to charge
Often a negotiated or established charge with each given reimbursement agent (Medicare, CDPHP, Medicaid all have set payment schedules)
established fee schedule for outpatient services
What do YOU think the OT manager has to consider when determining what to charge?
Time to complete
Level of complexity
Skill Required
Amount of direct supervision of the patient
Supply Expenses
Reimbursement Potential
Frequency of Services
RVU: Relative Value Unit
Coded charge Dollar amount also based on Relative Value Unit
HCPCS Codes
HCPCS = Healthcare Common Procedural Codes
Established in 1978
in outpatient CPT codes are used for
direct billing
iin in patient we still bill out codes but usually insurance companies aren’t going to see CPT codes meaning
used to demonstrate level of service provided
Outpatient:
CPT codes
used for direct billing
CPT Code: HCPCS Level I
Widely recognized by insurances and Medicare & Medicaid as standard coding
Time based codes: must pay attention to the minutes of therapy provided
therapeutic exercise, self care training, neuromuscular re-education
Service based codes: one unit no matter how much time it takes to complete
OT evaluation, splint fabrication, hot pack/cold pack
DME: Hixpix: HCPCS Level IIDurable Medical Equipment
Includes devices that are used at home for medical necessity
Wheelchair, walker, hospital bed
Does not cover basic expenses for adaptive equipment (not seen as medically necessary)
Purposes of Documentation
Chronological Record
legal list of what happened
Comply with Reimbursement
Medicare likes the words: function and safety
Communicate
call in sick…can someone pick up where you left off?
Clinical Reasoning
show you are providing a skilled OT service…if it looks like PT or looks like nursing or looks like Rec Therapy…guess who will be doing your job in the future!
Collect Data
Are you providing some quantitative demonstration of progress as well as qualitative?
Courtroom Defense
10 years from now can you or someone else tell what you did?
Point of Service Documentation
Document while you provide care
Reduce de-personalizing patient care during point of service documentation by:
Explaining why you are writing or typing so patient feels connected to what is happening
Pause writing when you are asking questions
Make eye contact while asking questions and for at least the beginning of the answer
