Billing and Insurance

Professional Responsibilities (Fees for service, ind health plans, gov insurance, reimbursement)

What is the fee for service payment model?

• Payers assume primary financial risk

• Enrollees have freedom of choice

• Unlimited access to specialists

• Co-payments are often 80/20

• Limited internal/external cost controls

• Minimal emphasis on health promotion and education

What is the managed care payment model?

• Providers share in financial risk

• Services provided by a specific pool of providers

• The primary care provider serves as a gatekeeper

• Provides services for a fixed, prepaid monthly fee

• Formal quality assurance and utilization review

• Health education and preventative medicine emphasize

*Includes HMO and PPO plans

Who is Medicare for?

Individuals 65 and older and the disabled

Medicare Part A

• Provides benefit for care provided in hospital, extended care facilities, hospice, and short-term care at home required by an illness for which the patient is hospitalized

• Enrollment is automatic, and funding is through payroll taxes (i.e. no monthly premius for those who qualify)

• Coninsurance is paid on a per-day basis after 60 days in the hospital

Medicare Part B

• Provides benefits for outpatient care, physician services, and services ordered by physicians such s diagnostic tests, medical equipment, and supplies

• Enrollment is voluntary, and funding is through premiums paid by beneficiaries and genral federal tax revenues

Medicare Part C

• Provides “bundled” benefits known as Medicare Advantage plans that cover all Medicare services (parts A and B, and usually part D)

• Enrollment is voluntary and is offered by private companies approved by Medicare; monthly premiums vary

Medicare Part D

• Provides at least a standard level of benefits for prescription drug coverage, including a list of medications (aka formulary)

• Enrollment is voluntary and funding is through premiums paid by beneficiaries

What is the maximum amount of days a person is covered for post hospital stays in extended care facilities?

100 days

In order for services to be reimbursed under Medicare Part B services, they cannot be rendered by a physical therapy aide/tech regardless of the level of supervision.

True

Who is Medicaid for?

The economically indigent population who qualify by reason of low income, welfare, or public assistance benefits in the state of their residence

• * Covers all inpatient and outpatient services, diagnostic services, nursing care for older adults, home health care, preventative health screening, and family planning services

How is Medicaid funded?

• Jointly by federal and state governments via personal income, corporate, and excise taxes

What is Worker’s Compensation and who is it for?

• A joint state and federally funded program designed to provide protection for employees that are injured on the job via income and coverage of medical expenses

• Employers with more than 10 employees or high risk employers must pay a percentage to this through each employees salary

Health maintenance organization (HMO)

Managed care insurance plan where the subscriber agrees to receive all of their health care services through the predetermined providers of the HMO

• The primary physician of the subscriber controls health care access through a referral system

• Cost containment is a high priority

• Subscribers cannot receive care from providers outside of the plan except in the case of emergencies

Preferred provider organization (PPO)

Manage care insurance plan where the subscribers can choose their health care services from a list of providers that contract the insurance plan

• Contracts provide extreme discounts

• Subscribers can use a providers outside of the plan, but they will assume more cost

Current procedural terminology (CPT) codes

• Procedure codes used by PTs, PTAs and other healthcare providers to describe the care given to a patient

• Most of the codes used in PT are in the 97000 series

• Include timed (based on 15 in rule) and untimed codes (1 unit regardless of time)

CPT code reimbursement amount varies depending on the contract and the specific insurance company being billed.

True

International Classification o Diseases (ICD) codes

Codes used primarily by physicians to describe a patient's infirmity based on etiology and affected anatomical systems; can sometimes be used by a PT without being considered a medical diagnosis (which PTs are not allowed to make)