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.