Third Party Reimbursement

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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?.

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Third Party Reimbursement

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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 97022 Whirlpool 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 Completeness Improper forms, lack of clear description of patient progress, lack of client info, improper coding, incomplete forms, no Dr. referral Timeliness Treatment administered too soon, tardy documentation, late filing of claim, outdated prescriptions, excessively long duration of care Compliance 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 Daily journal Individual patient accounts form Treatment note 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

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