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