Third Party Reimbursement

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Third Party Reimbursement
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What is 3rd Party Reimbursement?

• Reimbursement for services rendered
• A 1st party payer patient
• A 2nd party payer healthcare provider
• A 3rd party payer insurer
• 3rd party payers pay for some or all of the
  healthcare services of the patient

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Why do Athletic Trainers want to be able to Bill
for services rendered?

• It is important to be able to receive payment for
  services rendered
• It is difficult to retain personnel when there is
  financial strain
• Personnel must be able to document their value
  () to employers
• It pays the bills
• Covers salaries, purchases equipment supplies,
  covers other expenses incurred
• It may be required for the Athletic Trainer to
  keep a job!

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Codes

• International Classification of Disease (ICD)
• Tells insurance companies what is wrong with the
  patient as assessed by a physician
• Diagnostic-related Group (DRG)
• Used by Medicare other insurers to classify
  illnesses according to diagnosis treatment
• Current Procedural Terminology (CPT)
• Developed by AMA Dept. of Coding Nomenclature
• Provider is anyone licensed to provide services
• Universal Billing (UB)
• Similar to CPT codes
• Describe the services provided (designed for use
  in hospital settings by American Hospital
  Association)

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ICD Codes

• Specific Examples
• 717.4 Derangement of Lateral Meniscus
• 735.2 Hallux Rigidus
• 836.50 Dislocation of Knee

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DRG Codes

• Fixed amounts of payment are assigned to each DRG
  in advance and paid on a per-case basis
• Designed for acute, hospital care, where the
  pre-established reimbursement structure was paid
  to the provider regardless of services provided
• This type of reimbursement has led to may ethical
  behaviors of providers. This may not be a
  financially sound classification system.

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CPT Codes

• American Medical Association Dept. of Coding
  Nomenclature
• 5-digit numbers that represent treatment provided
• 97005 Athletic Training Evaluation
• 97006 Athletic Training Reevaluation
• 97022 Whirlpool
• 97014 Electrical stimulation (unattended)
• 97113 Aquatic Therapeutic Exercise (ea. 15 mins.)

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UB Codes

• Similar to CPT codes
• Used to describe services provided
• Designed for use in hospital settings

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Athletic Training Services Billing

• Many 3rd party payers are not familiar with
  athletic trainers. Claims will be rejected if
  they are unfamiliar with athletic trainers.
• Once an athletic trainer has been recognized by a
  payer, claims may not be rejected.
• Athletic training practice is not protected by
  licensure in all states.

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State Regulation www.nata.org
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Should Athletic Training Services be Reimbursed?

• Payers may ask for any of the following when
  determining what should be reimbursed
• Is athletic training practice regulated by the
  state?
• Is this service you provided within your scope of
  practice?
• If athletic training is not regulated by the
  state, is there a national credential, such as
  certification, that would describe your training?
• Are you providing a service within the scope of
  your certification?

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Most Common Reasons for Claim Denial

• Appropriateness
• Inappropriate or unnecessary service rendered,
  treatment not matching Dr.s orders, no
  pre-certification, lack of patient progress
• Completeness
• Improper forms, lack of clear description of
  patient progress, lack of client info, improper
  coding, incomplete forms, no Dr. referral
• Timeliness
• Treatment administered too soon, tardy
  documentation, late filing of claim, outdated
  prescriptions, excessively long duration of care
• Compliance
• No home program established or followed,
  unrealistic goals, nonfunctional goals, unsafe
  delivery of services, not following 3rd party
  guidelines, patient noncompliance, lack of
  progress, patient absence of treatment sessions,
  lack of reevaluations

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Third Party Payers

• HMOs 5 models
• Staff or closed-panel model HMO directly
  employs healthcare providers
• Group model HMO contracts with a multispecialty
  group to provide services
• Network model just like group except several
  provider groups render care rather than just one
• Independent practice association or open-panel
  model providers belong to an independent
  association that negotiates a contract with the
  HMO
• Individual provider model contracts made with
  individual healthcare providers
• Providers are guaranteed a predetermined
  amount for each member in the plan regardless of
  whether they actually treat them (prepaid
  healthcare or capitation)

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Third Party Payers

• PPOs like closed-panel HMOs
• Treat only patients enrolled in the plan
• PPOs are actively negotiating discounted rates
  for individuals in their plan
• PPOs allow choice of provider, but if non-PPO
  provider is selected, the amount of services
  covered is reduced

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Documentation to be Submitted

• Make sure the form is complete and the proper
  codes have been inputted
• Forms that may be used for insurance companies
• Patient registration form
• Patient encounter form
• Daily journal
• Individual patient accounts form
• Treatment note
• Insurance claim form

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Filing the Claim

• Find out who will file the claim (patient or
  provider)
• Find out what is covered by the patients
  insurance company
• Make sure you have been assigned a provider
  number
• Do you need a physician referral in order to be
  reimbursed?
• Obtain appropriate form(s)
• Communicate with the insurance company

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Denied Claims

• Review the patients coverage language
• If the coverage language supports payment, write
  an appeal letter describing the disorder its
  medical nature
• Letter should include facility info, date of
  appeal, reminder of original date of claims
  submission, recipients name address, provider
  information, patient info, date of service
  total charges, claim number, reiteration of
  reason for denial, explanation of why charges
  should be paid
• The patient may have to file a complaint with the
  small claims court
• A formal complaint may be submitted to the state
  insurance commissioner

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NATA Committee on Reimbursement

• http//www.nata.org/members1/committees/cor/rag.cf
  m