INSURANCE

Page 1: Introduction to Administrative Aspects

• PTAS 103 Administrative Aspects

  • Focus on Therapy Settings, Financing, Reimbursement

Page 2: Communist Health Service System

• Existed in the Soviet Union before 1992

• Characteristics:

  • No privately owned medical systems

  • Highly government-controlled

  • Healthcare as a RIGHT of citizenship (entitled, free)

  • Access issues: basic and acute care available to all only by the 1980s

  • Medications purchased from government pharmacies at no cost

  • Physicians provide most healthcare services

Page 3: Socialist Health Services (Germany)

• Recognizes limited private ownership

• Mandated health insurance since 1883

  • Services free for citizens funded by taxes

• Solidarity principle for equitable distribution via union memberships

• Unique financing structure through companies and trade associations

• Positives: Accessibility is better than communist systems

• Negatives: Limited communication between public and private sectors

Page 4: Comprehensive Health Care System (UK)

• Centralized planning with decreased government control

• Universally available services with private options

• Health funded through public taxes and payroll taxes

• Direct payments required for dental and medications

• Overall satisfaction reported, although access issues exist

• Waiting times for specialists reported as manageable

• Gate keeper - GP specialists requires referral

Page 5: Welfare System - Canada

• Hybrid system: decreased central government involvement, increased private participation

• Canadian Medicare provides comprehensive rights to health services for all ages

• Negatives: Increased waiting times, limited outpatient services

• Coordination and administration shared with federal government

• Private insurance available for additional services, often utilized for care outside of Canada

Page 6: Entrepreneurial Health Services System - US

• Predominantly private systems supported by minimal public funding

• Lack of defined health as a "right" in Constitution

• Major component of healthcare is private expenditure

• Variety of payer services including Medicare and Medicaid

• High costs per patient compared to global averages

Page 7: Changes Over Time Affecting PT

• Increased documentation requirements

• Shift in service locations and reduced length of stay

• Increased demand with staffing reductions

• Rise of transdisciplinary approaches and evidence-based practices

• Influence of Telehealth and quality assurance measures

Page 8: Transdisciplinary Team Approach

• Teamwork minimizes duplication of services

• Coordination of care enhances efficiency and effectiveness

• Utilization of comprehensive evaluation data to inform treatment plans

Page 9: Money Movement in Health Financing

• Overview of financing: individual payment vs. insurance reimbursement

• Types of payment models:

  • Out-of-pocket payments

  • Individual and Employment-based Private Insurance

  • Government-financed healthcare models

• Reimbursement models:

  • Retrospective payments (after service rendered)

  • Prospective payments (before services rendered)

Page 10: Financing Types

• Out of Pocket: Individual pays directly without insurance

  • Affordable healthcare remains an issue for low-income groups

• Individual Private Insurance: Direct purchase of insurance policy with various limitations

• Employment-Based Private Insurance: Cost-sharing structure driven by community rating

Page 11: Employment-Based Private Insurance

• Originated from WWII wage wars

• Employers typically cover 80% of premium costs

• Community rating spreads risk across all enrollees

Page 12: Finance and Reimbursement Terms

• Definitions of key financial terms:

  • Premium: monthly cost

  • Deductible: payment before coverage kicks in

  • Co-pay: portion split between insurer and insured

Page 13: Out of Pocket Expenses Explained

• Differentiation between in-network and out-of-network services

• Explanation of 'usual and customary' charges affecting reimbursements

Page 14: Health Savings Accounts (HSA) and Flexible Savings Accounts (FSA)

• HSA benefits: contributions by employers and employees, tax reductions

• FSA operates with annual loss of unspent funds, no employer contributions

Page 15: Reimbursement Methods Explained

• Fee-for-service model with CPT code reimbursements

• Variances in payment structures for in-network versus out-of-network services

Page 16: Types of Insurance: HMO vs. PPO

• HMO: Restrictive network requiring referrals and primary care physician gateways

• PPO: More choices and flexibility without needing referrals, but higher costs

Page 17: Bundling and Workmen’s Compensation

• Bundling: Combined service payments with reduced rates for additional services

• Workmen’s Compensation: Coverage for work-related injuries, with employer-sponsored policies

Page 18: Government-supported Insurance - Medicare

• Overview of eligibility criteria for Medicare coverage

• Components of Medicare: Parts A and B with varying services covered

Page 19: Medicare Parts Breakdown

• Medicare Part A: Covers inpatient services, long-term care, hospice

• Medicare Part B: Covers outpatient services, including therapy and diagnostics

Page 20: Medical Necessity Under Medicare

• Criteria defining medical necessity in service provision

Page 21: Conditions for Medicare Reimbursement

• Service requirements to demonstrate improvement potential to qualify for Medicare services

Page 22: Medicaid Overview

• Coverage for low-income individuals with state-controlled details

• Services required at the federal level, but states have discretion

Page 23: Medicaid Service Limitations

• Specificities of terminology in service documentation to ensure approval

Page 24: Factors Affecting Facility Survival

• Critical factors: Profit margin management, staffing levels, patient volume, treatment effectiveness

Page 25: Co-Morbidity Concepts

• Definition and consequences of co-morbid conditions affecting treatment outcomes

Page 26: Length of Stay Trends in Healthcare

• Observations on reduced lengths of stay and discharge statuses impacting care needs

Page 27: Patient and Caregiver Education Requirements

• Increased need for education upon patient discharge due to complex care requirements

Page 28: Acute Care Services Defined

• Short-term skilled services based on patient stabilization

• Daily treatment metrics and prospective payment system insights

Page 29: Sub-Acute Care Services Explained

• Comprehensive inpatient quantity required for skilled nursing and rehabilitation

Page 30: Home Health Care Services Overview

• Characteristics of service provision in a home-based environment for rehabilitation

Page 31: Hospice Services Specifications

• Eligibility and service scopes focused on terminal patients

Page 32: Physical Therapy in Hospice Care

• PT roles in enhancing functional capabilities within home settings

Page 33: Classification of Preventive Services

• Definitions of primary, secondary, and tertiary prevention with examples

Page 34: Back to Work Rehabilitation

• Focus on work-related therapy approaches and assessment tools to support recovery

Page 35: Conclusion and Acknowledgements

• Presentation wrap-up with contact information for further inquiries.