What is 3rd Party Reimbursement?. Reimbursement for services renderedA 1st party payer = patientA 2nd party payer = healthcare providerA 3rd party payer = insurer3rd party payers pay for some or all of the healthcare services of the patient. Why do Athletic Trainers want to be able to Bill for services rendered?.
1. Third Party Reimbursement
2. What is 3rd Party Reimbursement? Reimbursement for services rendered
A 1st party payer = patient
A 2nd party payer = healthcare provider
A 3rd party payer = insurer
3rd party payers pay for some or all of the healthcare services of the patient
3. Why do Athletic Trainers want to be able to Bill for services rendered? It is important to be able to receive payment for services rendered
It is difficult to retain personnel when there is financial strain
Personnel must be able to document their value ($$$) to employers
It pays the bills
Covers salaries, purchases equipment & supplies, covers other expenses incurred
It may be required for the Athletic Trainer to keep a job!
4. Codes International Classification of Disease (ICD)
Tells insurance companies what is wrong with the patient as assessed by a physician
Diagnostic-related Group (DRG)
Used by Medicare & other insurers to classify illnesses according to diagnosis & treatment
Current Procedural Terminology (CPT)
Developed by AMA Dept. of Coding & Nomenclature
“Provider” is anyone licensed to provide services
Universal Billing (UB)
Similar to CPT codes
Describe the services provided (designed for use in hospital settings by American Hospital Association)
5. ICD Codes Specific Examples
717.4 Derangement of Lateral Meniscus
735.2 Hallux Rigidus
836.50 Dislocation of Knee
6. DRG Codes Fixed amounts of payment are assigned to each DRG in advance and paid on a per-case basis
Designed for acute, hospital care, where the pre-established reimbursement structure was paid to the provider regardless of services provided
This type of reimbursement has led to may ethical behaviors of providers. This may not be a financially sound classification system.
7. CPT Codes American Medical Association Dept. of Coding & Nomenclature
5-digit numbers that represent treatment provided
97005 Athletic Training Evaluation
97006 Athletic Training Reevaluation
97014 Electrical stimulation (unattended)
97113 Aquatic Therapeutic Exercise (ea. 15 mins.)
8. UB Codes Similar to CPT codes
Used to describe services provided
Designed for use in hospital settings
9. Athletic Training Services Billing Many 3rd party payers are not familiar with athletic trainers. Claims will be rejected if they are unfamiliar with athletic trainers.
Once an athletic trainer has been recognized by a payer, claims may not be rejected.
Athletic training practice is not protected by licensure in all states.
10. State Regulation – www.nata.org
11. Should Athletic Training Services be Reimbursed? Payers may ask for any of the following when determining what should be reimbursed:
Is athletic training practice regulated by the state?
Is this service you provided within your scope of practice?
If athletic training is not regulated by the state, is there a national credential, such as certification, that would describe your training?
Are you providing a service within the scope of your certification?
12. Most Common Reasons for Claim Denial Appropriateness
Inappropriate or unnecessary service rendered, treatment not matching Dr.’s orders, no pre-certification, lack of patient progress
Improper forms, lack of clear description of patient progress, lack of client info, improper coding, incomplete forms, no Dr. referral
Treatment administered too soon, tardy documentation, late filing of claim, outdated prescriptions, excessively long duration of care
No home program established or followed, unrealistic goals, nonfunctional goals, unsafe delivery of services, not following 3rd party guidelines, patient noncompliance, lack of progress, patient absence of treatment sessions, lack of reevaluations
13. Third Party Payers HMOs – 5 models
Staff or closed-panel model – HMO directly employs healthcare providers
Group model – HMO contracts with a multispecialty group to provide services
Network model – just like group except several provider groups render care rather than just one
Independent practice association or open-panel model – providers belong to an independent association that negotiates a contract with the HMO
Individual provider model – contracts made with individual healthcare providers
Providers are guaranteed a predetermined $$ amount for each member in the plan regardless of whether they actually treat them (prepaid healthcare or capitation)
14. Third Party Payers PPOs – like closed-panel HMOs
Treat only patients enrolled in the plan
PPOs are actively negotiating discounted rates for individuals in their plan
PPOs allow choice of provider, but if non-PPO provider is selected, the amount of services covered is reduced
15. Documentation to be Submitted Make sure the form is complete and the proper codes have been inputted
Forms that may be used for insurance companies
Patient registration form
Patient encounter form
Individual patient accounts form
Insurance claim form
16. Filing the Claim Find out who will file the claim (patient or provider)
Find out what is covered by the patient’s insurance company
Make sure you have been assigned a provider number
Do you need a physician referral in order to be reimbursed?
Obtain appropriate form(s)
Communicate with the insurance company
17. Denied Claims Review the patient’s coverage language
If the coverage language supports payment, write an appeal letter describing the disorder & its medical nature
Letter should include: facility info, date of appeal, reminder of original date of claims submission, recipient’s name & address, provider information, patient info, date of service & total charges, claim number, reiteration of reason for denial, explanation of why charges should be paid
The patient may have to file a complaint with the small claims court
A formal complaint may be submitted to the state insurance commissioner
18. NATA Committee on Reimbursement http://www.nata.org/members1/committees/cor/rag.cfm