Revenue and Reimbursement – Nuts and Bolts

1. Revenue and Reimbursement – Nuts and Bolts Presented by Linda Fabrizio Mazzoli MS, ATC, PTA, PES NATA District II COR

2. 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

3. Objectives - Cont’d • Outline some basic processes for third party reimbursement • Outline basic processes for reimbursement denial • Give you resources to start your journey!

4. Revenue Generation Opportunities • Hospital - outpatient • Hospital - inpatient • Hospital - physician extender • College / secondary schools - Independent • College / secondary schools - union • Physician extender

5. Revenue Generation Opportunities • Sole Proprietor - Outpatient Rehabilitation • Independent contractor • Industrial • Professional sports • DME / Protective bracing • Military • Consultant

6. 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.

7. ATs – Services that we provide as Diverse Healthcare Providers • Education • Risk Management • Prevention Services • Organization and Management Services • Rehabilitation • Injury Evaluation • Event coverage • Etc.

8. Worth of Services = Revenue • With a clear definition of services, comes a clear understanding of Worth. • Fee Schedules • Regional, National Rates • Competitor Rates

9. Types of Reimbursement in those opportunities • CASH • Contract Rates • Case Rates • HSA • Self Pay • Third Party

10. Reimbursement Cash is KING!

11. Reimbursement • Contract Rates – • School Contracts • Educational Inservices • Coding and Documentation Training • Advisement of SOP Manual • Teaching

12. Reimbursement • HealthCare Spending Accounts • Newest wave of reimbursement • More employers encouraging these accounts • Discounts for employee participation • Prevention is key service

13. Reimbursement • Case Rate • Rehabilitation of an ACL injury • Job Task Analysis • Documentation Audit • Self Pay • Fitness evaluation • Rehabilitation • No different than cash

14. Reimbursement • THIRD PARTY • Reimbursement is for everything • Detailed process • Documentation, documentation, documentation • Market driven • Politically driven • Satisfying • Professionally enhancing

15. Reimbursement • Third Party • Insurances • Poorest form of reimbursement to providers • Highest form of reimbursement from consumers

16. Third Party Reimbursement • Types of Insurance Plans • Contracting • Coding and Documentation • Billing Processes • Reimbursement • Appeals

17. Types of Insurance Plans • Service provider • Indemnity payments • Managed care • Others

18. 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

19. 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

20. Managed Care • HMO • EPO • PPO • POS

21. 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

22. 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

23. 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

24. 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)

25. 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

26. 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

27. 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

28. 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

29. Processes For Billing Third Party Insurances • Contracting Process • Credentialing Process • Billing Process • Collection Process • Appeals Process

30. Third Party Contracting - Definitions of Reimbursement • Time Based • Fee For Service • Flat Rate • Case Rate • Capitation

31. Hold Harmless Gag Clause Favored Nation Exclusivity Mandatory Time Limit/ Super session Termination Quality Contract Renegotiation Evergreen Contracting - Know the lingo

32. Definitions within contract • 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

33. 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)

34. 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

35. 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

36. Billing Process • Code Utilization • Fee Schedules • Claim Filing • Form Utilization • Time Frames

37. 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

38. 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

39. 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)

40. 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

41. 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

42. 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

43. Code utilization • Use codes as they are defined • Use codes for services provided only • Use codes for the time spent providing the service only • Document/code for EVERY modality/procedure provided

44. 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

45. 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

46. 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

47. 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

48. 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.

49. Appropriateness Completeness Compliance Timeliness Denial of ClaimCommon mistakes into 4 areas

50. 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