Reimbursement for Physical Therapy Services, Part I
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Questions and Answers

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)?

  • 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?

  • 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?

    <p>It encourages providers to offer more treatments since payment is based on quantity, not quality.</p> Signup and view all the answers

    What is a typical characteristic of cost-sharing in health insurance?

    <p>It involves beneficiaries contributing to healthcare costs in various forms, such as copays and deductibles.</p> Signup and view all the answers

    Which of the following describes a situation where a patient pays for health care services directly?

    <p>Self Pay</p> Signup and view all the answers

    What type of insurance program is characterized by coverage under a state or federal partnership?

    <p>Medicaid</p> Signup and view all the answers

    Which term refers to the amount a patient must pay out-of-pocket before their insurance starts to cover services?

    <p>Deductible</p> Signup and view all the answers

    What is a characteristic of Managed Medicaid?

    <p>It is managed by a private insurance company.</p> Signup and view all the answers

    What defines the services covered and excluded by health insurance plans like Medicaid or CHIP?

    <p>State program rules</p> Signup and view all the answers

    Which statement accurately describes Personal Injury Insurance?

    <p>It provides coverage for the insured and passengers for medical needs after an accident.</p> Signup and view all the answers

    Which of the following health plans does NOT require a monthly payment from beneficiaries?

    <p>Medicaid</p> Signup and view all the answers

    Which of the following is an example of a benefit paid by Workman’s Compensation?

    <p>Financial support for medical services due to workplace injuries</p> Signup and view all the answers

    What is a potential consequence of patient financial abilities on healthcare services?

    <p>Financial abilities can limit service frequency and quality.</p> Signup and view all the answers

    How can payment restrictions affect physical therapy services?

    <p>They create a requirement for physical therapy before pain management interventions can occur.</p> Signup and view all the answers

    Which of the following is a documentation requirement that can impact physical therapy service coverage?

    <p>A plan of care must have physician signatures for Medicare.</p> Signup and view all the answers

    In what way are durable medical equipment coverage restrictions significant?

    <p>Patients are limited to replacement wheelchairs every 5 years.</p> Signup and view all the answers

    What impact does the high administrative burden have on physical therapy practices?

    <p>It complicates the management of patient records and insurance claims.</p> Signup and view all the answers

    What is the implication of payment denials in physical therapy?

    <p>Denials can occur retroactively even after prior authorization.</p> Signup and view all the answers

    What requirement must be met for home health aide coverage under Medicare?

    <p>Patients must be receiving skilled physical therapy or registered nursing care.</p> Signup and view all the answers

    What limit is commonly placed on interventions regarding physical therapy visits?

    <p>There may be a cap on the dollar amount covered per condition annually.</p> Signup and view all the answers

    What is the primary feature of a Health Maintenance Organization (HMO)?

    <p>Closed network with lower copays for in-network services</p> Signup and view all the answers

    Which payment model shifts more cost responsibilities to employees?

    <p>High Deductible Health Plan (HDHP)</p> Signup and view all the answers

    In value-based payment systems, what does 'Quality' specifically refer to?

    <p>Successful patient outcomes</p> Signup and view all the answers

    Which term describes a fixed amount that a patient must pay for each healthcare visit?

    <p>Copay</p> Signup and view all the answers

    What does the concept of prospective payment imply in healthcare?

    <p>Payments are based on predetermined criteria honoring quality</p> Signup and view all the answers

    What challenge in the current healthcare system is primarily driven by secretive pricing agreements among hospitals?

    <p>Rising healthcare bills for consumers</p> Signup and view all the answers

    What is a common misconception regarding fee-for-service payment models?

    <p>Providers are rewarded based on patient outcomes</p> Signup and view all the answers

    Which stakeholder is most affected by the risk-sharing aspect of employee health plans?

    <p>Employers providing health benefits</p> Signup and view all the answers

    What is the primary responsibility of physical therapists in relation to Principle 7A of the Code of Ethics?

    <p>Promoting environments that allow for autonomous professional judgments.</p> Signup and view all the answers

    Which factor is NOT mentioned as a concern regarding medication management in home health settings?

    <p>Inadequate staff training for medication administration.</p> Signup and view all the answers

    What is implied as a critical aspect of documentation in relation to reimbursement?

    <p>It plays a key role in securing payment for services provided.</p> Signup and view all the answers

    In the context of ethical responsibilities, what should a therapist do if unable to fulfill obligations to patients?

    <p>Refrain from the employment arrangement.</p> Signup and view all the answers

    What is a key principle underlying value-based care models?

    <p>Quality divided by cost.</p> Signup and view all the answers

    Which behavior is essential for therapists to avoid potential fraud, waste, and abuse in billing?

    <p>Maintaining detailed notes on patient interactions.</p> Signup and view all the answers

    In the situation described, who is responsible for making medication changes for patients?

    <p>The therapist already present with the patient.</p> Signup and view all the answers

    Which of the following commitments reflect the Code of Conduct for physical therapists?

    <p>Engaging in practices that support societal well-being.</p> Signup and view all the answers

    What significant change was made at the Virginia Mason Medical Center to improve patient care?

    <p>Created an integrated system where caregivers work collaboratively</p> Signup and view all the answers

    Which of the following metrics indicates the effectiveness of the new system at Virginia Mason?

    <p>Fewer days of work missed by patients</p> Signup and view all the answers

    Which of the following actions would most likely violate anti-kickback laws?

    <p>Receiving cash from a DME supplier for referrals</p> Signup and view all the answers

    What was the impact on physical therapy visits after implementing the new system at Virginia Mason?

    <p>Reduction in average visits to 4.4 per episode</p> Signup and view all the answers

    What conditions must be met for a physical therapist to waive coinsurance and deductible amounts?

    <p>The patient demonstrates financial need after reasonable requests for payment</p> Signup and view all the answers

    How did the revenue approach change at Virginia Mason Medical Center?

    <p>Increased revenue through enhanced productivity</p> Signup and view all the answers

    What was one of the observed benefits of the integrated spine clinic system at Virginia Mason?

    <p>Decrease in unnecessary medical tests</p> Signup and view all the answers

    Which type of improper billing involves charging for services not rendered?

    <p>Fraudulent billing</p> Signup and view all the answers

    What does the approach of penalizing poor outcomes in care aim to improve?

    <p>Quality and efficiency of healthcare delivery</p> Signup and view all the answers

    Which of the following is considered improper billing in physical therapy regarding aides?

    <p>Billing for services rendered by aides without proper supervision</p> Signup and view all the answers

    What is a direct consequence of the changed system for managing low back pain at Virginia Mason?

    <p>Fast tracking of severe cases for immediate attention</p> Signup and view all the answers

    What is a common type of improper coding that results in higher billing?

    <p>Upcoding</p> Signup and view all the answers

    What might lead to a government inquiry regarding patient incentives?

    <p>Offering small gifts for patient referrals</p> Signup and view all the answers

    What outcome regarding hospital readmission rates was noted at Virginia Mason's Spine Clinic?

    <p>Readmission rates significantly decreased</p> Signup and view all the answers

    Billing for a physical therapy service that exceeded its authorized visits is an example of which type of misconduct?

    <p>Fraudulent billing</p> Signup and view all the answers

    What constitutes a violation when a physical therapist engages with patients concerning financial agreements?

    <p>Offering to waive payment for all patients at a clinic</p> Signup and view all the answers

    Which principle of the APTA Code of Ethics directly emphasizes the importance of trustworthiness and compassion in patient interactions?

    <p>Principle 2</p> Signup and view all the answers

    What does Principle 7A of the APTA Code of Ethics call for regarding professional practices?

    <p>Promoting environments that support professional judgment.</p> Signup and view all the answers

    Which ethical concern does the scenario described highlight regarding physical therapy documentation practices?

    <p>Potential engagement in healthcare fraud.</p> Signup and view all the answers

    Which principle encourages physical therapists to refrain from employment if they cannot meet professional obligations?

    <p>Principle 7F</p> Signup and view all the answers

    Which aspect of Principle 8 guides therapists in collaborative efforts outside their practice?

    <p>Participating in health initiatives at various levels.</p> Signup and view all the answers

    What is a primary reason for the need to reduce waste in healthcare as mentioned in the content?

    <p>Manage health for as many people as possible.</p> Signup and view all the answers

    Which of the following actions would NOT be in line with ethical practice as described in the APTA Code of Ethics?

    <p>Selecting inaccurate outcome measures for a patient.</p> Signup and view all the answers

    What key issue is raised when a therapist is trained to manipulate documentation outcomes?

    <p>Erosion of ethical standards in physical therapy.</p> Signup and view all the answers

    What is the minimum duration of direct treatment a therapist must provide to bill Medicare for a time-based CPT code?

    <p>Eight minutes</p> Signup and view all the answers

    How does Medicare determine the number of units that can be billed for therapy services?

    <p>By totaling minutes and dividing by 15</p> Signup and view all the answers

    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?

    <p>6 units</p> Signup and view all the answers

    Which resource should therapists consult for compliance guidance in relation to potential fraud or abuse?

    <p>CMS local Medicare Administrative Contractors</p> Signup and view all the answers

    What is the reasoning behind the statement that 'PTs can’t isolate themselves' in value-based payment models?

    <p>Collaboration among providers influences overall patient outcomes.</p> Signup and view all the answers

    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?

    <p>2 units</p> Signup and view all the answers

    What must a therapist be aware of regarding the total minutes of therapy service provided to ensure proper billing?

    <p>The need to accumulate certain time segments for billing purposes</p> Signup and view all the answers

    Which of the following CPT codes is NOT categorized as a time-based code?

    <p>Hot/cold packs (97010)</p> Signup and view all the answers

    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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    Related Documents

    Reimbursement for Physical Therapy Services, Part 1 PDF
    Payment Part 2 Policy Key Issues PDF

    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.

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