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Athletic Training Management. Chapter 11 Third Party Reimbursement Edited by Jeff Konin, Ph.D., ATC, MPT. AT and 3 rd party Reimbursement. Athletic training has its own CPT code and can already bill for services Only effective if insurance will pay

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athletic training management

Athletic Training Management

Chapter 11

Third Party ReimbursementEdited by Jeff Konin, Ph.D., ATC, MPT

at and 3 rd party reimbursement
AT and 3rd party Reimbursement
  • Athletic training has its own CPT code and can already bill for services
    • Only effective if insurance will pay
    • Many third party payers are not familiar with athletic training
    • We do NOT have a Medicare billing clearance
      • Many insurance companies follow Medicare’s lead
    • Claims my be rejected for any number of reasons (see table 11.1)
importance of billing
Importance of Billing
  • 3rd party reimbursement represents acceptance of the profession as an allied healthcare profession
    • It is a means to offering enhanced professional recognition, job security, and wage improvements
  • Income generated pays your salary and benefits
    • While not every service is billed in all settings at this time, successful billing has occurred in all settings
importance of billing1
Importance of Billing
  • May be a potential income source in college, pro, and high school settings
  • With ever increasing costs in athletic departments, the need for 3rd party reimbursement is growing
    • Can add budget stability to an athletic program rather than be a drain
  • Many athletic trainers are reluctant to bill as an ethical issue
importance of billing2
Importance of Billing
    • It is important to remember that all services are already billed, the bill is paid by athletics, usually in advance, but still paid
  • Generating revenue for services provided may help off-set management concern for elevating salaries
what is a third party payer
What is a Third-Party Payer
  • The patient is the first party, the medical professional the second party and the insurance carrier the third party
  • Traditional insurance like BC/BS, Aetna, Mutual of Omaha, etc.
  • Managed Care Organizations
    • Groups of either defined providers or customers or both to give access and manage health care costs
    • See Chapter 10
reimbursement codes
Reimbursement Codes
  • Basic information is submitted in a standardized coding format so that proper processing can occur
  • Codes representing the diagnosis of a problem are according to the International Classification of Diseases (ICD)
  • Codes documenting treatment procedures are Current Procedural Terminology (CPT) codes or universal billing (UB) codes
reimbursement codes1
Reimbursement Codes
  • The treatment intervention must always match the intervention code in order for a 3rd party to pay
  • For 3rd party payers the CPT or UB codes are matched to the ICD codes to ensure appropriate interventions
reimbursement codes2
Reimbursement Codes
  • International Classification of Disease codes (ICD) tell the insurer the specific diagnosis
    • Any service provider would use the same code for the same condition
    • Used to determine appropriateness of the procedures delineated by CPT code
reimbursement codes3
Reimbursement Codes
  • 845 – Sprains and strains of the foot and ankle
  • 845.0 – ankle
  • 845.00 – unspecified site
  • 845.01 – deltoid (ligament), ankle
  • 845.02 – calcaneofibular (ligament)
  • 845.03 – tibiofibular (ligament), distal
  • 845.09 – other
  • 845.1 – foot
  • 845.10 – unspecified site
  • etc.
reimbursement codes4
Reimbursement Codes
  • DRG codes
    • Diagnostic-related group is a system of classification used by Medicare and other insurers to classify illnesses according to diagnosis and treatment
    • Fixed amounts of payment are assigned to each DRG in ADVANCE and paid on a per-case basis
    • Originally designed for acute hospital care
reimbursement codes5
Reimbursement Codes
  • CPT codes
    • Current Procedural Terminology codes are developed by the AMA Department of Coding and Nomenclature
    • Provider as defined in CPT codes is anyone who is licensed to provide services
    • Therapist is a generic term and refers to no specific profession
      • Payment is often decided not on the type of therapist, but on whether or not the therapist is licensed or approved to perform the intervention
reimbursement codes6
Reimbursement Codes
  • 97005 – athletic trainer evaluation
  • 97006 – athletic trainer reevaluation
  • 97010 – application of modality to one or more areas; hot or cold packs
  • 97012 – traction, mechanical
  • 97014 – electrical stimulation (unattended)
  • 97016 – vasopneumatic devices
  • 97018 – paraffin bath
  • 97020 – microwave
  • 97022 – whirlpool
  • 97024 – diathermy
  • 97032 – electrical stimulation (one-on-one) for trigger point
reimbursement codes7
Reimbursement Codes
  • 97033 – iontophoresis (each 15 min)
  • 97035 – ultrasound
  • 97110 – therapeutic exercise (each 15 min)
  • 97116 – gait training (each 15 min)
  • 97124 – massage (each 15 min)
  • 97139 – taping general
  • 29280 – hand/finger strapping/taping
  • 29530 – knee strapping/taping
  • 29540 – ankle strapping/taping
  • etc.
reimbursement codes8
Reimbursement Codes
  • Universal Billing (UB) code are similar to CPT codes and used in hospitals
preparing documentation
Preparing Documentation
  • Documents should be developed providing accurate comprehensive information about a patient’s condition and treatment intervention and that conforms to the requirements of 3rd party payers
  • Minimum needs include patient registration form, a patient encounter form (fig 11-1), a daily journal, an individual patient’s accounts form, a treatment note, and insurance claims forms (fig 11-2 HCFA- 1500 and UB-92)
filing a claim
Filing a Claim
  • First determine whether the patient or you will file the forms
    • Find out from the payer if you must be assigned a provider number
    • They will tell you how to file a claim with them
    • Review the patient’s policy to determine what is covered
    • Be sure to inform patients that they are ultimately responsible for the bill
    • Physician referral is often required to be reimbursed
filing a claim1
Filing a Claim
  • Obtain necessary claim forms
  • You will need to indicate the physician diagnosis and the treatment provided
    • Use ICD-9-CM and CPT or UB codes
    • Correct coding is essential
    • Filing for managed care organizations is similar to non-managed care
  • Communication with the carrier is essential
  • Use of the required forms is essential
submitting the claim
Submitting the Claim
  • Can be submitted either in written or electronic form
  • Trend is electronic to speed filing and decrease the paper trail
  • Completeness and accuracy is a must
  • Missing, inaccurate, or incomplete data, or data not conforming to the electronic billing system will cause denial
handling denied claims
Handling Denied Claims
  • Go back and review the patient’s policy to reestablish patient’s coverage limitations
  • Write an appeal letter if the service should be covered
    • Include any new data that supports the claim
    • It they still refuse, consider referring the patient to small claims court
    • Also file a complaint with the state insurance commissioner
handling denied claims1
Handling Denied Claims
  • The appeal letter should include the following information:
    • Facility information (name, address, phone)
    • Date of appeal
    • Reminder of original date of claims submission
    • Recipient’s name and address
    • Provider information (name, address, provider number, tax number)
    • Patient information (name, address, phone, insurer identification number)
    • Date of service and total charges
handling denied claims2
Handling Denied Claims
  • Claim number
  • Reiteration of the reason for denial
  • Explanation of why charges should be paid
communicating with payers
Communicating with Payers
  • Many insurers will have no experience with athletic trainers
  • You may need to provide the necessary information on education, licensure, certification status, etc.
  • If you are communicating over a denied claim for reasons other than if you are an eligible provider, method of communications is important
communicating with payers1
Communicating with Payers
  • Communications should be direct, use practical and functional terms, and universally understood medical terminology
  • You may have to explain grading systems for various conditions
  • You should always document the names, dates, and times with whom you spoke
challenges to third party reimbursement
Challenges to Third-Party Reimbursement
  • Because athletic training is not credentialed in all 50 states, it is necessary for athletic trainers to demonstrate to payers the worthiness for payment
  • As long as the athletic trainer meets the same requirements as other reimbursable providers that were set up by a 3rd party payer, within both federal and state law and scope of practice, reimbursement should be possible
challenges to third party reimbursement1
Challenges to Third-Party Reimbursement
  • Payers may ask for any of the following when determining reimbursement
    • Is athletic training regulated by the state
    • Is the service within you scope of practice
    • If athletic training is not regulated at the state level, is there a national credential such as certification
    • Are you providing service within the scope of certification