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Introduction to Medical InsuranceTina Patel GunaldoPT, PhD, DPT, MHS
Objectives Understand the common terminology
that surrounds medical insurance, billing and reimbursement.
Apply ASHA Code of Ethics Principles related to billing to case examples.
Who Pays for Healthcare? Centers for Medicare and Medicaid Services (CMS)
Medicare: Medicare Part A/Part B Age 65, Disabled/under age of 65, ALS
Medicaid: Early Steps/Part C Eligibility varies by state
Worker’s Compensation (WC) TRICARE Commercial Insurance (Blue Cross Blue Shield, United
Healthcare, Cigna, etc.) Third Party Private Pay
Indigent/Uninsured Care
Who Pays for Healthcare?
http://www.statehealthfacts.org/comparebar.jsp?
ind=125&cat=3&sub=39&yr=274&typ=2&o=a
Kaiser Family Foundation
Billing and Reimbursement Billing
Amount billed by health care provider for services a patient has received
Reimbursement Amount paid by an individual or
organization for services
Billed Amount ≠ Reimbursed Amount
InsuranceBilling and Reimbursement May change according to Practice Setting
Inpatient Acute or Psyc (IP) Long Term Acute Care (LTAC) Inpatient Rehabilitation Facility (IRF) Skilled Nursing Facility (SNF) Nursing Home (NH) Home Health (HH) Outpatient (OP) – Hospital-based or Private Practice School System Early Steps
May change according to the insurance type (primary and secondary)
May change according to documentation (reimbursement) - skilled services, Non Payable G Codes, Severity Modifiers, PQRS
May change according to documentation (billing) – CCI Edits, Non Payable G Codes, Severity Modifiers, KX Modifers, CPT Codes
Medicare Part A
Also known as Hospital Insurance. It helps to cover inpatient acute care in hospitals, long-term care, rehabilitation, psychiatric, critical access hospitals, and skilled nursing facilities. Also included is hospice care and some home health.
Monthly premium $441 for those who are not eligible; otherwise there is no monthly premium
Part B Also known as Medical Insurance. It helps to cover doctor services and outpatient
care. It can cover some other medical services that Part A doesn’t cover . Covered services and supplies should be medically necessary.
Monthly premium and annual deductible apply. Based on yearly income and tax return filed.
Part C – advantage health plan
Part D – prescription drug plan Premium based on yearly income and tax return filed.
Medicaid Funded jointly by federal and state government
Through the Federal Medical Assistance Percentage (FMAP) payments, states receive matching dollars to pay for a portion of Medicaid
Louisiana Hospital Service Provider Manual Page 27 (One evaluation every 180 days – prior
approval not needed); prior approval needed for treatment – SLP CPT codes 92506 and 92507
Reimbursement – Eval fluency $77.70; Eval Production $63.31; Eval sp/lang $131.19; Eval voice $65.93; Treatment $27.20 per session
Payment Systems Fee-for-Service Episode Payment
Single price for an entire episode of care (all services needed in inpatient and outpatient)
Comprehensive Care Payment Condition-adjusted capitation/risk adjusted
Single price for all services needed by a group for a fixed period of time
http://www.chqpr.org/downloads/WhichPaymentSystemisBest.pdf
ICD-9-CM Codes International Classification of Diseases,
9th revision, Clinical Modification Developed by World Health Organization Describe the patient condition/diagnosis Required to be reimbursed May guide billing (CPT codes)
ICD-10-CM/PCS Codes Tenth Revision (Clinical Modification/Procedure
Coding System) CM – diagnosis coding (used in all US Healthcare
settings) World Health Organization
PCS – inpatient procedure coding (used in US inpatient hospital settings) Used to collect data, determine payment and support electronic health record
All healthcare entities must be in compliance by 10/2015 according to HIPAA (Administrative Simplification provisions)
CMS Fact Sheet
ICD-10-CM/PCS CodesICD-9-CM ICD-10-CM
388.01 PresbyacusisH91.1 Presbycusis Presbyacusia
H91.10 Presbycusis, unspecified ear
H91.11 Presbycusis, right ear
H91.12 Presbycusis, left ear
H91.13 Presbycusis, bilateral
784.43 Hypernasality R49.21 Hypernasality
784.51 DysarthriaR47.1 Dysarthria and anarthria
ASHA Resources
Payment Systems Prospective Payment System (PPS)
Based on a predetermined, fixed amount – classification system Home Health – predetermined rate for each
60-day episode of care Home Health Resource Groups (HHRG) Reported via Outcome and Assessment
Information Set (OASIS –after October 1, 2014) OASIS assessment may need to be completed by the
SLP if this is the only therapy service ordered or if ordered along with occupational therapy only.
Therapy Services and Visits - page 77-81http://www.chqpr.org/downloads/WhichPaymentSystemisBest.pdf
Payment Systems Prospective Payment System (PPS)
Inpatient PPS (IPPS) Acute Inpatient
Diagnosis Related Groups (DRG) Hospice Inpatient Psychiatric Inpatient Rehabilitation
Case-Mix Groups (CMG) reported in Patient Assessment Instrument (PAI)
Long-Term Care Hospitals Skilled Nursing Facility
Reports via Minimum Data Set (MDS) Outpatient PPS (OPPS)
Hospital Outpatient (Relative Value Units (RVU)
http://www.chqpr.org/downloads/WhichPaymentSystemisBest.pdf
Example Diagnosis Related Groups (DRGs) –
patient classification scheme that relates patient case mix to costs. DRGs – used by CMS AP-DRGs – All Patient- more
representative of non-Medicare patients APR-DRGs – All Patient Refined – combo of
DRG and AP-DRG
Example Prospective Payment System (PPS) for IP
Rehab Facility Patient cases are categorized using the
Patient Assessment Instrument (IRF-PAI – page 46-48; 86-95)) for Medicare Part A recipients and reimbursement is based upon the PAI
What type of patients having Medicare as an insurance type can be accepted into an IRF - page I-3 60% of admitted patient population must have
the indicated diagnoses Reimbursement Guidelines
Example Prospective Payment System (PPS) for
SNF Facility Patient cases are categorized using the
Resource Utilizations Groups (RUGs) for Medicare Part A recipients
The Minimum Data Set (MDS) is completed to determine reimbursement for CMS
Example Hospital Outpatient Prospective Payment
System
Skilled Care CMS Update on Restorative Therapy and
Maintenance Therapy
CPT Codes Health Care Financing Administration
Common Procedure Coding System Uniform Coding System
Level I – CPT Codes Level 2 – HCPCS Codes - certain supplies,
transportation, drugs, DME, pathology, P&O, etc. services not listed in CPT codes
CPT Codes Physician’s Current Procedural
Terminology Developed by the American Medical
Association (AMA) Generally updated annually and effective
January Standardizes medical and surgical
procedures Required for most insurance programs for
processing claims and reimbursement
CPT Codes Time vs. Service CPT Codes
Time Direct one-on-one patient care 15-120 minutes Can bill more than one unit daily per discipline per
patient
Service Generally untimed Bill one unit daily per discipline per patient
Exception Can bill more than one unit per day if patient is seen at
separate time (am/pm treatments) Document
Insurance Terminology Copayment
A form of cost sharing where the patient pays a fixed dollar amount when a medical service is received.
Deductible A form of cost sharing where, within a benefit period,
a patient pays for medical expenses before the insurance company begins to make payments.
Coinsurance A form of cost sharing where the patient pays a
percentage of medical expenses after the deductible amount is paid.
Insurance Plans Indemnity Plan - plan that reimburses the patient and/or
provider as expenses are incurred; Fee for Service plan Greatest freedom of patient choice
Preferred Provider Organizations (PPO) – plan with a network of providers, where patient is allowed more freedom to seek medical care without referrals from PCP (in network and out-of-network opportunities)
Point of service plans (POS) - HMO and PPO hybrid Health Maintenance Organizations (HMO) – plan with a
network of providers, where patient selects a primary care physician (PCP) and additional referrals are made through this medical office; PCP = Gatekeeper Low premiums for patients
Exclusive provider organizations (EPO) – plan where care is restricted to in-network only, no out-of-network benefits Most restrictive for patients
Fraud and Abuse The federal government does not have
information on the exact dollar amount lost to fraud and abuse, but it estimated at approximately 3-10% of billing.
Fraud and Abuse Fraud
“Intentional deception or misrepresentation that someone makes, knowing it is false, that could result in unauthorized payment. Keep in mind the attempt itself is fraud, regardless of whether it is successful.”
Abuse “Involves actions that are inconsistent with accepted, sound
medical, business, or fiscal practices. Abuse directly or indirectly results in unnecessary costs to the program through improper payments.”
The real difference between fraud and abuse is the person's intent. Both activities have the same impact: they detract valuable resources.
www.cms.gov
Fraudulent Behaviors Billing for services not rendered Billing for non-medically necessary
treatment Upcoding of services actually rendered
www.cms.gov
Healthcare Fraud and Abuse Control Program (HCFAC)
Public Law 104-191 (HIPPA of 1996) established HCFAC, under the Attorney General and the Secretary of the Department of Health and Human Services acting via the Office of Inspector General (OIG)
Coordinates federal, state and local law enforcement activities with respect to health care fraud and abuse.
Designed to prevent health care fraud, waste and abuse in both public sectors.
HCFAC Program Assessment
Office of Inspector General (OIG) Mission - Protect the integrity of
Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries. Fights waste, fraud and abuse in Medicare
and Medicaid OIG 2014 Work Plan
Ethics SLP Code of Ethics
WELFARE of PERSONS SERVED Shall not discriminate Shall not charge for services not rendered
Example Shall not discontinue services without reasonable
notice
www.cms.gov
Ethics PROFESSIONAL COMPETENCE
Engage in only those aspects of the professions that are within the scope of practice and individual competence
www.cms.gov
Ethics RESPONSIBILITY TO THE PUBLIC
Shall not defraud in connection with payment, reimbursement, grants, research Example
www.cms.gov
Ethics RESPONSIBILITIES TO THE PROFESSION
Shall not engage in dishonesty, fraud, deceit, misrepresentation Example
www.cms.gov
Documentation Follow guidelines provided by
Board of Examiners – www.labespa.org National Association – www.asha.org Insurance Companies/Payers
Aetna Clinical Policy Bulletin - Speech Aetna Clinical Policy Bulletin – Voice CMS
Scope of Practice Follow guidelines provided by
Board of Examiners – www.labespa.org National Association – www.asha.org
Class AssignmentPrepare for class on Friday, May 30th
Bring a patient note to class