Show Me the Money- Delivering Ethical and Reimbursable Services within Healthcare Payer Sources Amber Heape, MCD, CCC-SLP, CDP Clinical Specialist- PruittHealth

Amber Heape- Disclosures Relevant Financial Relationships: Salaried Clinical Specialist for PruittHealth Receives honoraria for CE courses and seminars taught, including this one Relevant Non-Financial Relationships: Former SCSHA Board Member

Course Objectives The learner will classify major payer sources and requirements for skilled rehabilitation services within each source. The learner will compare and contrast documentation requirements for each payer source. The learner will apply ethical principles to reimbursement scenarios in order to synthesize information gained in this session.

Most Common Payor Types Medicare Medicaid Private Insurance

Medicare- Health insurance program that covers those eligible: age 65 or older, some disabled under 65, people of all ages with ESRD (dialysis or transplant).

Medicare Part A (Hospital Insurance/ Rehab) Pays for care in hospital, SNF (rehab), hospice, and some home health Payment based on ProspectivePayment System (RUGS levels) Most people get when they turn 65, as long as they or spouse worked and paid Medicare taxes Medicare Supplement Policies: (HMOA) Individual policies vary, some are RUGs payment based, some are set fee per day.

Medicare Part B (Medical Insurance- usually in addition to part A) Doctor’s services, outpatient hospital care, outpatient or inpatient therapy, some home health care Pay a monthly premium, just like insurance, and often have a copayment for services

Medicare Part D (Pharmacy/ prescription drug plan) Pay a monthly premium

Medicaid Joint federal and state program that pays medical costs for people with limited income and resources Usually helps pay costs (co pays) not covered by Medicare Also offers some assistance with personal care and transportation to dr. appts. Payors include Community Medicaid (patients live at home) and Long-Term Care Medicaid (patients live in SNF)

Rules for Medicare Part A Rehab In order to qualify for an inpatient rehab stay paid by Medicare: – Must be Medicare qualified – Be admitted (not observation) in hospital for 3 midnights – Pays 100% of first 20 days of inpatient rehab – Typically pays 80% of next 80 days of rehab. Balance paid by insurance or privately – Continued rehab dependent on continued progress during those 100 days – If you are d/c from the hospital, you have 30 days to begin an inpatient program Once in inpatient rehab, Medicare part A pays a “per diem” rate based on the RUG (Rehab Utilization Group) level of the patient

Medicare RUGs System In 2010, the case mix classification system (RUG IV system) was revised. Payment is based on the number of therapy minutes, as well as the medical complexity of patient, including levels for ADL status.

Medicare RUGs System Rehab Ultra High: – 720 minutes (5 days one discipline/ 3 days another) Rehab Very High: – 500 minutes (5 days/ 1 discipline) Rehab High: – 325 minutes (5 days/ 1 discipline) Rehab Medium: – 150 minutes (5 distinct days of therapy in a combination of disciplines) Rehab Low: – 45 minutes (3 days, any combination) RUGS determined by looking back 7 days from the ARD or Change of Therapy review. The ARD is determined by rehab director/ department head

Why am I assigned a specific number of minutes with each patient?

Medicare Part B- Therapy Part B pays per unit or service billed (by therapy type) There is no set amount of time per patient. Typical Speech Therapy CPT Codes are billed per service – (Treatment of Speech/Language) – (Treatment of Dysphagia)

Treatment Delivery Co-Treatment- Treatment between 2 disciplines no longer has to be split in time between the two. You must document the reason for co- treatment and goals your discipline focused on. Individual vs. Group treatment – Medicare pays group up to 25% of total billed minutes per discipline on part A’s. – Medicare Part B reimbursement rate for group therapy is very low, so often discouraged Concurrent treatment- “Dovetailing”- treating up to 4 patients simultaneously, with all working on different goals.

Supportive Diagnosis Coding Typically use the acute medical diagnosis for hospitalization as the therapy POC medical diagnosis. Also code using the diagnosis that most affects the patient’s need for Speech Therapy Should tie the diagnosis in narrative of reason for referral

Documentation Physician Orders Required by EVERY payor type for evaluation and/or treatment of the patient Physician “Cert” – Medicare Part A therapy services included and signed every 30 days – Medicare Part B POC must be signed by MD

Ethics and Clinical Judgment

Thank You!