Reimbursement for Physical Therapy Services, Part 1 PDF

Reimbursement for Physical Therapy Services, Part I Key Terms and Implications on Practice Matt Garber, PT, DSc Board Certified Orthopaedic Clinical Specialist Fellow, AAOMPT Associate Professor The George Washington University ...

Reimbursement for Physical Therapy Services, Part I Key Terms and Implications on Practice Matt Garber, PT, DSc Board Certified Orthopaedic Clinical Specialist Fellow, AAOMPT Associate Professor The George Washington University  Objectives  Differentiate between health plan models  Utilize proper insurance terminology when discussing payment issues https://www.apta.org/your-practice/payment  Reimbursement Sources  Private Insurance: Examples-Blue Cross, Aetna, Cigna, United Health Care, Kaiser Permanente  Federally Funded Insurance: Medicare, Military Coverage- Tricare, 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  Reimbursement Sources  Workman’s Compensation: a form of accident insurance paid by employers. Benefits are usually paid by a private insurance company or state run workers’ compensation fund.  Personal Injury Insurance/Medical Payment Insurance:  Additional coverage that can be added to Car Insurance to cover medical services needed from an accident-covers insured and passengers  Self Pay- patient pays for health care services  Pro Bono-free physical therapy services  Health Insurance Terms and Definitions  Premium: The amount the beneficiary pays each month for health care insurance. No premium for Medicare Part A and Part B or Medicaid.  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. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.  Health Insurance Terms and Definitions  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.  Deductible may be different for in- network and out- of-network providers.  Health Insurance Terms and Definitions  Co-pay: the fixed financial liability a patient has 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 for each service they provide from an approved list. This model gives incentives for providers to provide more treatments because payment is dependent on the quantity of care, rather than quality of care.  Health Insurance Terms and Definitions  Secondary Insurance: Coverage bought separately from a medical plan that helps cover care that your primary medical plan may not. Examples: Vision plan, dental plan, accidental injury plan.  Supplemental Health Insurance: Added medical coverage that can be purchased to contribute to paying the costs not covered by the primary health insurance plan, such as co-insurance, co-pays, and deductibles. With a supplemental Medicare insurance, Medicare pays 80%, Supplemental pays 20%  Health Insurance Terms and Definitions  PPO: Preferred Provider Organization: health plan models that allow patients to choose their own providers, however, there is a financial incentive to utilize the payer’s in-network providers and reduced coverage for out of network providers  HMO: Health Maintenance Organization- health plan models that have a closed network of providers and lower copays compared to Preferred Provider Organizations (PPOs); limits coverage to in-network providers Implications of Payment on Physical Therapy Services  Cost-Sharing: Except for Medicaid and Workman’s Compensation- almost all insurance companies employ cost-sharing-- beneficiaries must contribute in the payment of health care costs. Patients’ financial abilities greatly influence the amount of health care services that they receive Implications of Payment on Physical Therapy Services  Restriction of Coverage/Visits  Restricts where service can be received-In network or out of network  Limits number of visits  Denies payment for certain interventions  Caps the dollar amount per condition, per year, per lifetime  Restrictions of what services can be provided free: seen as incentives-Example: free nutrition services  Affects frequency, plan of care, functional outcomes Implications of Payment on Physical Therapy Services  Lack of Coverage of preventative services and ongoing PT Services for management of chronic conditions  Dictates Order of Interventions: Requires PT Services prior to other Pain Management Interventions  example: injections  Restrictions in PTA and Student Participation:  PTA to have decreased percentage of reimbursement  Direct one on one PT/Student delivery of care in Outpatient settings for Medicare Implications of Payment on Physical Therapy Services  Documentation Requirements:  Physician Referral required by some payers  Plan of Care must be signed by physician for Medicare  Progress Reports/Re-Evaluation required for continued coverage  CPT Codes for billing-restrictions of use of certain CPT codes  ICD-10 Use- only certain ICD-10 codes covered Implications of Payment on Physical Therapy Services  High Administrative Burden  Registration, Collection of Co-Pays, Deductibles  Insurance Verification  Authorization of Coverage  Billing  Coding  Procurement of Plan of Care Physician Signatures  HIPAA Compliance Implications of Payment on Physical Therapy Services  Denials:  Retroactive denials, even after authorization  Appeals process cumbersome  Patient responsibility for payment after denial Implications of Payment on Physical Therapy Services  Restrictions in Durable Medical Equipment (DME)/Complex Rehab Technology (CRT) Coverage  Replacement Wheelchairs restricted to every 5 years  Medicare covers DME/CRT for Home Use only  Home Health Aide Coverage Restrictions  Must be receiving skilled PT or RN to have aide coverage  Resources/References  https://www.apta.org/your-practice/payment  CMS.gov  Healthcare.gov