Third Party Payers

who finances healthcare

individuals, employers, government

3rd party payment has 3 gears to it, what are they

individual, provider, insurance plan

medicare

federally funded entitlement program for those 65 and older (and those who are disabled)

what is covered under medicare part A

• hospital insurance

• SNFs

• hospice care

• home health services

what is under medicare part B

• physician services

• outpatient hospital services

• medical equipment

• other services (like PT)

• select home care services

medicare advantage

• replaced medicare part C

• optional addition

• can choose managed care arrangements

medicare part D

funds prescriptions but is capped at a certain amount (this is kind of also under medicare advantage)

medicaid

state and federal govt funded healthcare for lower economic population (but state has authority)

some people have dual services which means what

they are medicare recipients but also have low income/limited resources so they qualify for other coverage as well

children’s health insurance program reauthorization act

expanded coverage of CHIP and SCHIP

provides coverage for children and pregnant women who don’t qualify for medicaid but can’t afford private health insurance

payment can be retrospective or prospective,,, what is the retrospective way

reimbursement later on from a “fee for service”

this is what traditional health insurance looks like

what are types of prospective payments

DRGs and RBRVS

DRG video:

one bundled payment that covers the entire episode of care

managed care organizations

HMO, PPO, POS

HMO (health management organization)

only provides in network coverage but is usually overall cheaper

predetermined payment schedule

PPO (preferred provider organization)

open managed care model: gives you access to in network and out of network providers

lower copay but usually higher deductible, no referral necessary

POS

point of service

RBRVS (resource based relative value scale)

equation based on total work completed, costs to practice medicine, and allowance for malpractice insurance expense

creates the RVU multiplied by a national conversion factor then geography

IDEA

individuals with disabilities act: increased funding in schools for children with disabilities

acute care payment

prospective: DRGs

• independent of services/length of stay (basically time doesn’t matter)

• rehab services are bundled into the DRG

• hospital makes money on some patients but not others

could be this flat fee with a co-pay

OR could be “per-diem, or private insurance

inpatient rehab payment system

prospective payment system (DRG)

non medicare payers have case managers to negotiate length of stay

inpatient rehab has 3 qualifications, what are they

need for intense rehab, ability to tolerate it over 3 hours a day, needing full team resources (physical, occupational, recreations, psychological, vocational, etc)

medicare 60 rule (2 parts)

60 day rule, 60% rule

60 day rule

any healthcare provider is legally required to refund any overpayment within 60 days

medicare rule 60%

60% of patients must come from a list of more complex rehab diagnoses

SNFs are covered under what

medicare A and B

SNFs are for continued treatment of an illness in which the person was hospitalized for __ days, but this must be within a __ day window after each hospitalization with maximum benefits of ___ days per “episode of illness”

3; 30; 100

the maximum benefit of 100 days per episode of illness in SNFs means that after 100 days of care what must happen in order to “restart the benefit”

the patient must be well for 60 days

in SNFs medicare pays for 100% for 20 days, after those initial 20 days though what happens

patient has an increasing copay

rehab services at SNF must

• require skill (unable to receive at home)

• not be custodial in nature (reasonable expectation of improvement)

how is billing categorized for SNFs

based on what particular RUG (resource utilization group) they are assigned to and number of therapy minutes they receive in a 7 day period

5 RUG categories

ultra high, very high, high, medium, low

home health care payment system

PPS (prospective payment system); 60 day episode payment; based on oasis tools

hospice care requirements

• patient must be terminal

• palliative care (not curative)

• hospice RN becomes case manager

• care is in the home, SNF, or inpatient hospice house

• provides RN, aide, social worker, and pastoral services

PTs role in hospice

quality of life, family teaching, maximize function, paid under arrangements with hospice

ACO (accountable care organization)

networks of healthcare providers that will be awarded financially if they slow the growth in their patients’ health care spending while maintaining or improving the quality of care they deliver

patient protection and affordable care act

PTs must abide by limitations or seek reimbursement directly from the patient

PTs must advocate for patient especially during times of healthcare reform to ensure they receive appropriate services