Podcast
Questions and Answers
What is the primary difference between supplemental health insurance and secondary insurance?
What is the primary difference between supplemental health insurance and secondary insurance?
- Supplemental health insurance only covers co-pays, while secondary insurance covers all medical expenses.
- Supplemental health insurance helps cover costs not included in a primary plan, whereas secondary insurance is a separate coverage that augments the primary medical plan. (correct)
- Supplemental insurance is usually derived from employer plans, while secondary insurance is individual-based.
- Supplemental insurance is limited to Medicare, while secondary insurance applies to all health plans.
What characterizes a preferred provider organization (PPO)?
What characterizes a preferred provider organization (PPO)?
- Patients have no choice in selecting their healthcare providers.
- It encourages patients to use in-network providers through financial incentives. (correct)
- It offers higher coverage levels for out-of-network providers than in-network providers.
- It charges lower premiums for patients preferring to always use out-of-network providers.
What is the concept of co-insurance in health insurance?
What is the concept of co-insurance in health insurance?
- A percentage of costs shared between the insurer and the insured after the deductible is met. (correct)
- A full coverage plan without any out-of-pocket expenses for the insured.
- A fixed amount required to be paid by the patient before coverage starts.
- An amount paid monthly by the insured to keep their policy active.
How does fee-for-service reimbursement impact healthcare providers?
How does fee-for-service reimbursement impact healthcare providers?
What is a typical characteristic of cost-sharing in health insurance?
What is a typical characteristic of cost-sharing in health insurance?
Which of the following describes a situation where a patient pays for health care services directly?
Which of the following describes a situation where a patient pays for health care services directly?
What type of insurance program is characterized by coverage under a state or federal partnership?
What type of insurance program is characterized by coverage under a state or federal partnership?
Which term refers to the amount a patient must pay out-of-pocket before their insurance starts to cover services?
Which term refers to the amount a patient must pay out-of-pocket before their insurance starts to cover services?
What is a characteristic of Managed Medicaid?
What is a characteristic of Managed Medicaid?
What defines the services covered and excluded by health insurance plans like Medicaid or CHIP?
What defines the services covered and excluded by health insurance plans like Medicaid or CHIP?
Which statement accurately describes Personal Injury Insurance?
Which statement accurately describes Personal Injury Insurance?
Which of the following health plans does NOT require a monthly payment from beneficiaries?
Which of the following health plans does NOT require a monthly payment from beneficiaries?
Which of the following is an example of a benefit paid by Workman’s Compensation?
Which of the following is an example of a benefit paid by Workman’s Compensation?
What is a potential consequence of patient financial abilities on healthcare services?
What is a potential consequence of patient financial abilities on healthcare services?
How can payment restrictions affect physical therapy services?
How can payment restrictions affect physical therapy services?
Which of the following is a documentation requirement that can impact physical therapy service coverage?
Which of the following is a documentation requirement that can impact physical therapy service coverage?
In what way are durable medical equipment coverage restrictions significant?
In what way are durable medical equipment coverage restrictions significant?
What impact does the high administrative burden have on physical therapy practices?
What impact does the high administrative burden have on physical therapy practices?
What is the implication of payment denials in physical therapy?
What is the implication of payment denials in physical therapy?
What requirement must be met for home health aide coverage under Medicare?
What requirement must be met for home health aide coverage under Medicare?
What limit is commonly placed on interventions regarding physical therapy visits?
What limit is commonly placed on interventions regarding physical therapy visits?
What is the primary feature of a Health Maintenance Organization (HMO)?
What is the primary feature of a Health Maintenance Organization (HMO)?
Which payment model shifts more cost responsibilities to employees?
Which payment model shifts more cost responsibilities to employees?
In value-based payment systems, what does 'Quality' specifically refer to?
In value-based payment systems, what does 'Quality' specifically refer to?
Which term describes a fixed amount that a patient must pay for each healthcare visit?
Which term describes a fixed amount that a patient must pay for each healthcare visit?
What does the concept of prospective payment imply in healthcare?
What does the concept of prospective payment imply in healthcare?
What challenge in the current healthcare system is primarily driven by secretive pricing agreements among hospitals?
What challenge in the current healthcare system is primarily driven by secretive pricing agreements among hospitals?
What is a common misconception regarding fee-for-service payment models?
What is a common misconception regarding fee-for-service payment models?
Which stakeholder is most affected by the risk-sharing aspect of employee health plans?
Which stakeholder is most affected by the risk-sharing aspect of employee health plans?
What is the primary responsibility of physical therapists in relation to Principle 7A of the Code of Ethics?
What is the primary responsibility of physical therapists in relation to Principle 7A of the Code of Ethics?
Which factor is NOT mentioned as a concern regarding medication management in home health settings?
Which factor is NOT mentioned as a concern regarding medication management in home health settings?
What is implied as a critical aspect of documentation in relation to reimbursement?
What is implied as a critical aspect of documentation in relation to reimbursement?
In the context of ethical responsibilities, what should a therapist do if unable to fulfill obligations to patients?
In the context of ethical responsibilities, what should a therapist do if unable to fulfill obligations to patients?
What is a key principle underlying value-based care models?
What is a key principle underlying value-based care models?
Which behavior is essential for therapists to avoid potential fraud, waste, and abuse in billing?
Which behavior is essential for therapists to avoid potential fraud, waste, and abuse in billing?
In the situation described, who is responsible for making medication changes for patients?
In the situation described, who is responsible for making medication changes for patients?
Which of the following commitments reflect the Code of Conduct for physical therapists?
Which of the following commitments reflect the Code of Conduct for physical therapists?
What significant change was made at the Virginia Mason Medical Center to improve patient care?
What significant change was made at the Virginia Mason Medical Center to improve patient care?
Which of the following metrics indicates the effectiveness of the new system at Virginia Mason?
Which of the following metrics indicates the effectiveness of the new system at Virginia Mason?
Which of the following actions would most likely violate anti-kickback laws?
Which of the following actions would most likely violate anti-kickback laws?
What was the impact on physical therapy visits after implementing the new system at Virginia Mason?
What was the impact on physical therapy visits after implementing the new system at Virginia Mason?
What conditions must be met for a physical therapist to waive coinsurance and deductible amounts?
What conditions must be met for a physical therapist to waive coinsurance and deductible amounts?
How did the revenue approach change at Virginia Mason Medical Center?
How did the revenue approach change at Virginia Mason Medical Center?
What was one of the observed benefits of the integrated spine clinic system at Virginia Mason?
What was one of the observed benefits of the integrated spine clinic system at Virginia Mason?
Which type of improper billing involves charging for services not rendered?
Which type of improper billing involves charging for services not rendered?
What does the approach of penalizing poor outcomes in care aim to improve?
What does the approach of penalizing poor outcomes in care aim to improve?
Which of the following is considered improper billing in physical therapy regarding aides?
Which of the following is considered improper billing in physical therapy regarding aides?
What is a direct consequence of the changed system for managing low back pain at Virginia Mason?
What is a direct consequence of the changed system for managing low back pain at Virginia Mason?
What is a common type of improper coding that results in higher billing?
What is a common type of improper coding that results in higher billing?
What might lead to a government inquiry regarding patient incentives?
What might lead to a government inquiry regarding patient incentives?
What outcome regarding hospital readmission rates was noted at Virginia Mason's Spine Clinic?
What outcome regarding hospital readmission rates was noted at Virginia Mason's Spine Clinic?
Billing for a physical therapy service that exceeded its authorized visits is an example of which type of misconduct?
Billing for a physical therapy service that exceeded its authorized visits is an example of which type of misconduct?
What constitutes a violation when a physical therapist engages with patients concerning financial agreements?
What constitutes a violation when a physical therapist engages with patients concerning financial agreements?
Which principle of the APTA Code of Ethics directly emphasizes the importance of trustworthiness and compassion in patient interactions?
Which principle of the APTA Code of Ethics directly emphasizes the importance of trustworthiness and compassion in patient interactions?
What does Principle 7A of the APTA Code of Ethics call for regarding professional practices?
What does Principle 7A of the APTA Code of Ethics call for regarding professional practices?
Which ethical concern does the scenario described highlight regarding physical therapy documentation practices?
Which ethical concern does the scenario described highlight regarding physical therapy documentation practices?
Which principle encourages physical therapists to refrain from employment if they cannot meet professional obligations?
Which principle encourages physical therapists to refrain from employment if they cannot meet professional obligations?
Which aspect of Principle 8 guides therapists in collaborative efforts outside their practice?
Which aspect of Principle 8 guides therapists in collaborative efforts outside their practice?
What is a primary reason for the need to reduce waste in healthcare as mentioned in the content?
What is a primary reason for the need to reduce waste in healthcare as mentioned in the content?
Which of the following actions would NOT be in line with ethical practice as described in the APTA Code of Ethics?
Which of the following actions would NOT be in line with ethical practice as described in the APTA Code of Ethics?
What key issue is raised when a therapist is trained to manipulate documentation outcomes?
What key issue is raised when a therapist is trained to manipulate documentation outcomes?
What is the minimum duration of direct treatment a therapist must provide to bill Medicare for a time-based CPT code?
What is the minimum duration of direct treatment a therapist must provide to bill Medicare for a time-based CPT code?
How does Medicare determine the number of units that can be billed for therapy services?
How does Medicare determine the number of units that can be billed for therapy services?
What is the highest number of units that can be billed for skilled therapy based on the 8-minute rule when 83 minutes of treatment is provided?
What is the highest number of units that can be billed for skilled therapy based on the 8-minute rule when 83 minutes of treatment is provided?
Which resource should therapists consult for compliance guidance in relation to potential fraud or abuse?
Which resource should therapists consult for compliance guidance in relation to potential fraud or abuse?
What is the reasoning behind the statement that 'PTs can’t isolate themselves' in value-based payment models?
What is the reasoning behind the statement that 'PTs can’t isolate themselves' in value-based payment models?
In the context of the 8-minute rule, how many units can be billed if a therapist provides between 23 and 37 minutes of treatment?
In the context of the 8-minute rule, how many units can be billed if a therapist provides between 23 and 37 minutes of treatment?
What must a therapist be aware of regarding the total minutes of therapy service provided to ensure proper billing?
What must a therapist be aware of regarding the total minutes of therapy service provided to ensure proper billing?
Which of the following CPT codes is NOT categorized as a time-based code?
Which of the following CPT codes is NOT categorized as a time-based code?
Flashcards
Premium
Premium
The amount the beneficiary pays each month for health care insurance. No premium for Medicare Part A and Part B or Medicaid.
Benefits
Benefits
The health care services that are covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents.
Deductible
Deductible
The amount of money the patient must pay out-of-pocket during the benefit period (typically one year) before a payer (insurer) reimburses for covered services. Plans may have individual and family deductibles.
Private Insurance
Private Insurance
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Federally Funded Insurance
Federally Funded Insurance
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Managed Medicare
Managed Medicare
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Managed Medicaid
Managed Medicaid
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Workman's Compensation
Workman's Compensation
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Co-pay
Co-pay
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Co-insurance
Co-insurance
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PPO (Preferred Provider Organization)
PPO (Preferred Provider Organization)
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HMO (Health Maintenance Organization)
HMO (Health Maintenance Organization)
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Cost-Sharing
Cost-Sharing
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Restriction of Coverage based on Network
Restriction of Coverage based on Network
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Limited Number of Physical Therapy Visits
Limited Number of Physical Therapy Visits
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Denied Physical Therapy Interventions
Denied Physical Therapy Interventions
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Caps on Physical Therapy Costs
Caps on Physical Therapy Costs
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Order Restricted Interventions
Order Restricted Interventions
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Restrictions on PTA and Student Participation
Restrictions on PTA and Student Participation
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Documentation Requirements for Physical Therapy Services
Documentation Requirements for Physical Therapy Services
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Administrative Burden of Physical Therapy Billing
Administrative Burden of Physical Therapy Billing
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Value Equation
Value Equation
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Value-Based Payment
Value-Based Payment
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High-Value Health Care Delivery System
High-Value Health Care Delivery System
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Prevention of Fraud, Waste and Abuse (FW&A)
Prevention of Fraud, Waste and Abuse (FW&A)
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Organization cost to provide services
Organization cost to provide services
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Patient Experience
Patient Experience
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Outcomes
Outcomes
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Prospective Payment
Prospective Payment
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Accountability for Cost and Quality of Care
Accountability for Cost and Quality of Care
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Improper Billing and Coding
Improper Billing and Coding
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Relationships with Referral Sources
Relationships with Referral Sources
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Relationships with Patients
Relationships with Patients
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FW&A: Fraud, Waste, and Abuse Prevention
FW&A: Fraud, Waste, and Abuse Prevention
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Organization Costs
Organization Costs
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8-minute Rule
8-minute Rule
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Time-Based CPT Codes
Time-Based CPT Codes
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Service-Based CPT Codes
Service-Based CPT Codes
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Unit Calculation for Time-Based CPT Codes
Unit Calculation for Time-Based CPT Codes
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Ethical Principle for PTs
Ethical Principle for PTs
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Promoting Autonomous Practice
Promoting Autonomous Practice
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Professional Obligations in Employment
Professional Obligations in Employment
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Importance of Documentation
Importance of Documentation
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Quadruple Aim
Quadruple Aim
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Fraud, Waste, and Abuse in Healthcare
Fraud, Waste, and Abuse in Healthcare
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Study Notes
Reimbursement for Physical Therapy Services, Part I
- This presentation covers key terms and practical implications of reimbursement for physical therapy services.
- The presenter is Matt Garber, PT, DSc, a Board Certified Orthopaedic Clinical Specialist and Fellow, AAOMPT, and Associate Professor at The George Washington University.
Objectives
- Differentiate between health plan models.
- Utilize proper insurance terminology when discussing payment issues.
Reimbursement Sources
- Private Insurance: Examples include Blue Cross, Aetna, Cigna, United Health Care, and Kaiser Permanente.
- Federally Funded Insurance: Medicare, Military Coverage (Tricare), and Veterans Health Administration.
- Managed Medicare: Medicare managed by a private insurance company.
- State/Federal Partnerships: Medicaid, Children's Health Insurance Program (CHIP).
- Managed Medicaid: Medicaid managed by a private insurance company (examples: Amerihealth, Amerigroup, Trusted).
- Workman's Compensation: Accident insurance paid by employers, usually by a private insurance company or a state-run workers' compensation fund.
- Personal Injury Insurance/Medical Payment Insurance: Additional coverage added to car insurance to cover medical services for accident-related injuries (covers insured and passengers).
- Self Pay: Patients pay for health care services.
- Pro Bono: Free physical therapy services.
Health Insurance Terms and Definitions
- Premium: The monthly amount paid by the beneficiary for health insurance (no premium for Medicare Part A & B or Medicaid).
- Benefits: Covered health care services under a health insurance plan. Defined in plan documents. Medicaid and CHIP benefits described in state program rules.
- Deductible: The amount a patient pays out-of-pocket before the insurance company reimburses. Individual and family deductibles exist. Deductibles can vary for in-network and out-of-network providers.
- Co-pay: A fixed financial liability for each visit to a specialist or primary care physician. Providers cannot waive co-pays.
- Co-insurance: The insured pays a percentage of the payment, after the deductible is met, in addition to the co-pay.
- Fee-for-service: Payers reimburse providers a fixed fee per service from an approved list. This model rewards quantity over quality.
- Secondary Insurance: Separate coverage (e.g., vision, dental, accidental injury) for care not covered by the primary plan.
- Supplemental Health Insurance: Additional coverage to help pay costs not covered by the primary plan (co-insurance, co-pays, deductibles). In the case of supplemental Medicare insurance, Medicare pays 80%, and the supplemental insurance pays 20%.
- PPO (Preferred Provider Organization): Health plan models that allow patients to choose their own providers, but give financial incentives for in-network providers. Reduced coverage for out-of-network providers.
- HMO (Health Maintenance Organization): Health plan models with a closed network of providers, lower co-pays compared to PPOs, and coverage limited to in-network providers.
Implications of Payment on Physical Therapy Services
- Cost-Sharing: Almost all insurance companies employ cost-sharing; beneficiaries contribute financially to health care costs. This affects healthcare services received.
- Restrictions of Coverage/Visits: Limits where services can be received (in-network or out-of-network), limits the number of visits, denies coverage for certain interventions, sets dollar caps per condition, year, or lifetime. Incentives for free services can also be restrictions.
- Lack of Coverage: Preventative services and ongoing physical therapy for chronic condition management may not be covered.
- Dictated Order of Interventions: Physical therapy may be required before other pain management interventions (e.g., injections).
- Restrictions in PTA and Student Participation: PTAs and students may have reduced reimbursement percentages. Restrictions on direct one-on-one PT/student delivery of care in outpatient Medicare settings.
- Documentation Requirements: Physician referral required by some payers. Plan of Care must be signed by a physician for Medicare. Progress reports/re-evaluations needed for ongoing coverage. Specific use of CPT codes for billing is restricted. ICD-10 codes may be restricted.
- High Administrative Burden: Registration, collecting co-pays, deductibles, insurance verification, authorization of coverage, billing, coding, procuring plan of care physician signatures, and HIPAA compliance are all administrative burdens.
- Denials: Retroactive denials, cumbersome appeals processes, and patient responsibility for payment after denial are common issues.
- Restrictions in Durable Medical Equipment(DME)/Complex Rehab Technology (CRT) Coverage: Replacement wheelchairs are often restricted to every 5 years. Medicare covers DME/CRT for home use only.
- Home Health Aide Coverage Restrictions: Requires skilled physical therapist or registered nurse (RN) coverage in addition to home health aide coverage.
Resources/References
- apta.org/your-practice/payment
- cms.gov
- Healthcare.gov
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Description
Explore the essential aspects of reimbursement for physical therapy services in this informative presentation. Key terms, health plan models, and various reimbursement sources are discussed, providing a comprehensive understanding for practitioners and students alike.
