Revenue and Reimbursement – Nuts and Bolts

Presented by

Linda Fabrizio Mazzoli

MS, ATC, PTA, PES

NATA District II COR

Objectives

• To Provide some basic understanding on Revenue and Reimbursement Arenas

• Discuss Types of Services and Revenue Opportunities

• Discuss Types of Reimbursement

• Review Third Party Reimbursement opportunities

Objectives - Cont’d

• Outline some basic processes for third party reimbursement

• Outline basic processes for reimbursement denial

• Give you resources to start your journey!

Revenue Generation Opportunities

• Hospital - outpatient • Hospital - inpatient • Hospital - physician extender • College / secondary schools - Independent• College / secondary schools - union

• Physician extender

Revenue Generation Opportunities

• Sole Proprietor - Outpatient Rehabilitation• Independent contractor• Industrial• Professional sports• DME / Protective bracing• Military• Consultant

Services

• Know what services you are providing– PM&R, Prevention, Impact Testing, Fitness,

Work Conditioning

• Clearly define your services– Taping vs. Prophylactic Strapping– Impact Testing or Neurocognitive Testing

• Clearly define your services associated with a payer.

ATs – Services that we provide as Diverse Healthcare Providers

– Education

– Risk Management

– Prevention Services

– Organization and Management Services

– Rehabilitation

– Injury Evaluation

– Event coverage

– Etc.

Worth of Services = Revenue

• With a clear definition of services, comes a clear understanding of Worth.

• Fee Schedules

• Regional, National Rates

• Competitor Rates

Types of Reimbursement in those opportunities

• CASH

• Contract Rates

• Case Rates

• HSA

• Self Pay

• Third Party

Reimbursement

Cash is KING!

Reimbursement

• Contract Rates – – School Contracts – Educational Inservices– Coding and Documentation Training– Advisement of SOP Manual – Teaching

Reimbursement

• HealthCare Spending Accounts– Newest wave of reimbursement– More employers encouraging these accounts– Discounts for employee participation– Prevention is key service

Reimbursement

• Case Rate– Rehabilitation of an ACL injury– Job Task Analysis– Documentation Audit

• Self Pay– Fitness evaluation– Rehabilitation– No different than cash

Reimbursement

THIRD PARTY Reimbursement is for everything Detailed process Documentation, documentation, documentation Market driven Politically driven Satisfying Professionally enhancing

Reimbursement

• Third Party– Insurances– Poorest form of reimbursement to providers– Highest form of reimbursement from

consumers

Third Party Reimbursement

• Types of Insurance Plans

• Contracting

• Coding and Documentation

• Billing Processes

• Reimbursement

• Appeals

Types of Insurance Plans

Service provider Indemnity payments Managed care Others

Service Provider

Blue Cross / Blue Shield Contracts directly with providers who are

paid at agreed rates for covered services Operates independently in each state or

region as state insurance codes allow

Commercial Insurance& Indemnity Plans

(Endangered Species)

Reimbursement on fee-for-service basis Generally 80/20 split plus deductibles Out of pocket expenses are capped Includes major medical catastrophic amount

Managed Care

HMO EPO PPO POS

HMO

Health Maintenance Organization Providers work for insurance company in its pure

defined form States vary on how this entity is defined Patient must use network providers to have

services covered Can create conflict of interest between the patient,

provider and the payor

More HMO

Patient pays copay No deductible Physician submits claims Provider paid according to set contract

agreements or are actually on payroll with bonuses for cost containment

Exclusive Provider Organization

EPO Hybrid of HMO and PPO Providers not employed by payor, but

limited, or closed panel, of payors Allows for patient to see only those on the

list or panel

EPO Continued

Benefits and services paid for as agreed to in policy

Provider has set limits of reimbursement per contract

No benefits or reduced benefits (only 60% of cost paid or even less)

Preferred Provider Organization(PPO)

Panels usually more open to providers Providers paid agreed upon rates Copay for patient, deductible varies Benefits reduced for seeing out of network

provider

Point of Service (POS) Pays providers of consumers choice Provider may have to agree to accept

payments as if in network Patient may be responsible for balance Only restriction is ability to pay and

services covered Similar to indemnity

Worker’s Compensation Insurance State mandated program for employees injured on

the job Benefits include medical coverage and possibly

lost wages depending on category Temporary Total Disability Permanent Partial Disability Permanent Total Disability Managed by commercial carrier or state operated

CHAMPUS and Medicare Federal programs that do not recognize ATCs at

this time Does not preclude ATC from treating those

patients, just can’t bill for services Can work within the same facility May change as the military hires more ATCs in

various settings Likely will take congressional action

Processes For Billing Third Party Insurances

• Contracting Process

• Credentialing Process

• Billing Process

• Collection Process

• Appeals Process

Third Party Contracting - Definitions of Reimbursement

• Time Based

• Fee For Service

• Flat Rate

• Case Rate

• Capitation

Contracting - Know the lingo

EvergreenContract Renegotiation

Quality

TerminationMandatory Time Limit/ Super session

Exclusivity

Favored NationGag ClauseHold Harmless

• Time Based: Reimbursed a fixed amount based on time increments, regardless of the services/procedures provided

• Fee for Service: Reimbursed for each service/procedure provided

• Flat Rate:Reimbursed fixed amount per visit regardless of number of services/procedures provided or amount of treatment time rendered

Definitions within contract

• Case Rate: Reimbursed a fixed amount per new patient case/episode of care

• Capitation: Reimbursed a pre-paid fixed amount for each person/member enrolled in the health plan regardless of services/procedures provided (PMPM rate)

Definitions within contract

Third Party Reimbursement:Payer Fee Schedule

You should know:• Their fee schedule• Services/codes not reimbursed• Documentation and communication requirements• Requirements for documentation of charges• When to document & charge for re-evaluation

Credentialing Process

State regulations - + & - Essentials to being reimbursed Individual credentialing vs facility Carrier recognition of allied health provider Get to know the provider relations representative -

know their process Detailed process - resume, CV, CEU, diploma May have to approach medical director of carrier

Billing Process

• Code Utilization

• Fee Schedules

• Claim Filing

• Form Utilization

• Time Frames

Code Utilization - ICD-9

ICD-9 CM – International Classification of Disease – Clinical Modifications

Diagnostic codes for standardized formatting of describing diagnosis

Indicate chronic, acute, disease, injury, condition Must match with appropriate CPT codes in billing

process

ICD-9

Must be consistent with referring provider Differences can cause delays or even denial of

claim being paid When initial, the vague or broad codes may be more

appropriate Refer to ICD-9 and CPT code manuals Learned system, cheat sheets with most common

are best Software available today for both

Code Utilization - HCPCS Codes

HCPCS - Health Care Financing Administration Common Procedure Coding

Healthcare’s Common Procedure Coding System, Levels I, II, III

HCPCS II describe supplies, procedures and services not listed in CPT (e.g. “L” codes for orthotics and splinting)

HCPCS III describe “local” codes (thru 1-1-03)

Code Utilization - CPT Codes

• CPT Codes - Current procedural Terminology Codes– Five-digit universal numerical code developed by

the AMA to describe procedure or service provided – Physical Medicine and Rehabilitation - commonly

used - 97000 Well over 8,200 codes Provides uniform language Allows for reliable nationwide communication

Why is CPT Used?

To report MD/DO and other medical providers services under public/private health insurance programs

Claims processing To develop guidelines for medical care

review Medical education & research

97000 SeriesEvaluation & Re-evaluation Codes

• 97001 – Physical Therapist Eval

• 97002 – Physical Therapist Re-Eval

• 97003 – Occupational Therapist Eval

• 97004 – Occupational Therapist Re-Eval

• 97005 – Athletic Trainer Eval

• 97006 – Athletic Trainer Re-Eval

Code utilization

Use codes as they are definedUse codes for services provided onlyUse codes for the time spent providing the

service only Document/code for EVERY modality/procedure

provided

Billing Process

HCFA 1500 - private setting UB - universal billing, hospital setting Most billing done electronically Fill fields properly Select correct codes Strive for “clean” claims

HCFA 1500

Form used for medical billing for Medicare, Medicaid, and commercial carriers (incl. worker’s compensation)

Specific information in each field Codes for everything, not just CPT Can be done via various software for print

or electronic submission

Universal Billing

UB forms Hospitals and clinics Mainly electronic Printed forms seldom used As in HCFA1500, fields filled in correctly Revenue code to designate type of provider

Claim Filing

• Four important step for Filing A Claim– 1. Good Documentation -

• “If it not written it is not done”• SOAP note format• Ensures quality work, outcomes and appropriateness

– 2. Preparation• This is probably the most important step b/c must

have a good working system

Claim Filing - cont’d.

– 3. Review

• In-House Audits or utilization review

– Healthcare providers review documentation and coding to ensure: Improve documentation, standard terminology, assess appropriateness of the plan of care, and determine further necessity of treatment

– 4. Submission

• Sending to the appropriate address or mail file electronically.

Denial of ClaimCommon mistakes into 4 areas

• Appropriateness

• Completeness

• Compliance

• Timeliness

Appealing Denied Claim

• Review the Explanation of Benefits• Understand why you are not getting paid• Review third party payer guidelines• Talk with third party payers• Maintain a encounter sheet when talking to payers• Prepare a Cover letter• Show outcomes

Outcomes

• Theory of a better outcome

• Collecting evidence based standards of care– NORA– Research

• Patient Satisfaction

• Quality of Standards

• Showing Cost savings

Comparison Cost Analysis of Rehabilitation CareOther Rehab providers vs. Athletic Therapist

Case study: A 24 y/o female patient reports to Physician with injured Left Ankle- Dx: Grade 3 Inversion sprain, care plan from MD indicates PWB as tolerated, taping for edema control, and referral for rehabilitation services indicating 3-4x/week for 4-6 weeks.

Initial Evaluation/Patient education 97001- PT provider 97005- AT provider

Plan of care development Care plan for 3x/week for 6 weeks 4x/week for week 1 then

Care transferred to PTA 2-3x/week ATC providers

Blue Cross payment (BNE plan) $57.92 $57.92

Week 1 97140 Manual therapy 97140 Manual therapy97014 Estim unattended 97014 Estim unattended

3 visits 97110 Ther Exs

4 visits

BCBSMA BNE fee per visit 3 x $49.50 = $148.50 4 x $49.50 = $198.00

Week 2 97140 Manual therapy 97110 Ther Ex

97014 Estim unattended 97112 Neuro Re-Ed

97110 Ther Exs 97032 Estim Attended

3 visits 3 visits

BCBSMA BNE fee per visit 3 x $49.50 = $148.50 3 x $49.50 = $148.50

Week 3 Same as week #2 Same as week #2

3 visits Add 97530 Func training

3 visits

BCBSMA BNE fee per visit 3 x $49.50 = $148.50 3 x $49.50 = $148.50

Week 4 97140 Manual therapy 97530 Func Training

97110 Ther Exs 97112 Neuro Re-ed

2 visits 2 visits

97002 PT re-eval 97006 AT re-eval

1 visit 1 visit

Continue RX progress to DC from program- return to

Functional exercise and MD for clearance to return to

Neuro re-training play. Continue with HEP and

Return to MD for Status check instruction for patient to f/up

w/ AT for safe return to play

BCBSMA BNE fee per visit 3 visits x $49.50 = $148.50 3 visits x $49.50 = $148.50

Week 5 97530 Func Training Total cost of service =

97112 Neuro Re-ed $701.42

BCBSMA BNE fee per visit 3 visits x $49.50 = $148.50

Week 6 97530 Func Training

97112 Neuro Re-ed

BCBSMA BNE fee per visit 3 visits x $49.50 = $148.50

Pt. Discharged from PT with short-term goals met, no further education on return to participation status, or re-injury risk.

Total cost of service = Total cost savings=

$948.42 247.50

Note: In this example the real possibility of the patient re-injuring her ankle and needing additional therapy or surgical intervention is potentially greater with the other healthcare provider model. This factor alone could potentially inflate the pay out for BCBSMA to 3-5x the initial cost of care provided by the AT provider.

ATCs are receiving reimbursement now!

• Insurance Companies

• Workers Comp.

• The Blues

• TPAs

• CASH!

• Many, Many More

How Do you get Started

• What do you currently have in Place– Athletic Training room standards of Care– Documentation– Policies and Procedures– You probably already have everything

“Instead of thinking about where you are, think about where you want to be. It takes twenty years of hard work to become an overnight success.”

Diana Rankin

“As you go through life, you find that if you don’t paddle your own canoe, you don’t move…”

Katherine Hepburn

Resources

• Your State COR

• Gather your resources– Documentation programs– Pain Questionnaires– Insurance companies

• NATA Web Site

• Toolboxes being Developed

Resources

Worker’s Comp: Key resources National Association of Insurance Commissioners

(NAIC) 816-374-7259 American Association of Health Plans (AHHP)

www.aahp.org Website clearinghouse for WC rules

www.dol.gov/dol/esa/public/owcp_org.htm www.comp.state.nc.us/ncic/pagrs/wcadmdir.htm

Resources Available

Additional Resources• ICD-9-CM AHA 312-422-3366• HCPCS II HCFA 410-786-3000• APTA: National Office APTA.org• Fax on demand:1-703-531-0866• APTA: Guide to PT Practice, coding manual

published with St. Anthony’s (1-02)

Resources Available

Additional Resources• The Center for Medicare Education• http://www.MedicareED.org• 202-508-1210• National information resource center for

professionals and volunteers who provide consumer education about Medicare

Resources• www.nata.org• www.cms.hhs.gov/manuals/pm_trans/

R1793B3.pdf

Resources Available

More Websites:• HCFA.gov/CMS.gov• Local Medical Review Policies: LMRP.NET• Ppsapta.org• APTA.org• PTManager.com• Complianceinfo.com• Compliance.com• HIPAAdocs.com

Resources Available

RBRVS Resources

• Medicare RBRVS: The Physician’s Guide 800-621-8335

• Use of the Resource-Based Relative Value Scale (RBRVS) Beyond Medicare

• Federal Register: November 1, 2000

• New Orders, Superintendent of Documents

• P.O. Box 371954

• Pittsburgh, PA 15250-7954

• 888-293-6498 (credit card) 202-512-2250 (fax)

• APTA Department of Government Affairs

Resources Available CPT Resources

• AMA Department of Coding & Nomenclature 800-621-8335• AMA CPT Assistant Publication/Mastering the Reimbursement

Process• APTA Guide to PT Practice, AOTA Practice Guidelines• APTA Department of Reimbursement, 800-999-2782, ext 8511• AOTA 800-877-1383

Resource Lists• Websites

• www.gopats.org

• www.nata.org

• www.cms.hhs.gov/medlearn

• www.oig.hhs.gov

• Any questions ?

Resource Lists• Reimbursement for Athletic Trainers by Marjorie J

Albohm with Dan Campbell and Jeff G Konin To Order call 1-800-257-8290 or email at Orders@slackinc.com

• CPT Codebook; written by AMA and published by St.Anthony’s Publishing

• ICD-9 CM Codebook, published by St.Anthony’s Publishing

• Mastering the Reimbursement Process, Published by the AMA

• Reimbursement manual 1 and 2 by the NATA

QUESTIONS

?????

Thank You!Linda Fabrizio Mazzoli

MS,ATC, PTA, PES

Cooper Bone and Joint Institute

856-912-0416

NATA District II COR

PATS COR Co-Chair