Introduction to Medical Insurance Tina Patel Gunaldo PT, 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)(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? ar.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

Insurance Billing 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 of up to $407 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 (page 33)page 33  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 Louisiana Hospital Service Provider Manual  Page 27 (One evaluation every 180 days – prior approval not needed); prior approval needed for treatment – SLP CPT codes and  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 ymentSystemisBest.pdf

ICD-9-CM Codes  International Classification of Diseases, 9 th 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 CMS Fact Sheet

ICD-10-CM/PCS Codes ICD-9-CMICD-10-CM Presbyacusis H91.1 Presbycusis Presbyacusia H91.10 Presbycusis, unspecified ear H91.11 Presbycusis, right ear H91.12 Presbycusis, left ear H91.13 Presbycusis, bilateral Hypernasality R49.21 Hypernasality Dysarthria R47.1 Dysarthria and anarthria ASHA Resources

Payment Systems  Prospective Payment System (PPS)  Based on a predetermined, fixed amount – classification systempredetermined, fixed amount – classification system  Home Health – predetermined rate for each 60- day episode of care  Home Health Resource Groups (HHRG)(HHRG)  Reported via Outcome and Assessment Information Set (OASIS – quality reporting) (Star Ratings)OASIS – quality reportingStar Ratings  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 Therapy Services and Visits - page ymentSystemisBest.pdf

Payment Systems  Prospective Payment System (PPS)  Inpatient PPS (IPPS)  Acute Inpatient  Diagnosis Related Groups (DRG)(DRG)  Hospice Hospice  Inpatient PsychiatricPsychiatric  Inpatient RehabilitationRehabilitation  Case-Mix Groups (CMG) reported in Patient Assessment Instrument (PAI)  Long-Term Care Hospitals Long-Term  Skilled Nursing Facility Skilled Nursing  Reports via Minimum Data Set (MDS)  Outpatient PPS (OPPS)  Hospital Outpatient (Relative Value Units (RVU) ymentSystemisBest.pdf

Example  Diagnosis Related Groups (DRGs) – patient classification scheme that relates patient case mix to costs. Diagnosis Related Groups (DRGs)  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 Prospective Payment System (PPS)  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 PAIPatient Assessment Instrument (IRF-PAI – page 46-48; 86-95))  What type of patients having Medicare as an insurance type can be accepted into an IRF - page I-3page I-3  60% of admitted patient population must have the indicated diagnoses  Reimbursement Guidelines Reimbursement Guidelines  CMS is proposing to add a new item to the inpatient rehabilitation facility- patient assessment instrument (IRF-PAI) that would require IRFs to record how much and what type of therapy (i.e., individual, group, co-treatment) patients receive in each therapy discipline (i.e., physical therapy, occupational therapy, and speech-language pathology), similar to what is currently reported on the minimum data set in the skilled nursing facility setting.  On or after 10/1/2015 –  Concurrent – one therapist with 2 patients performing different activities  Co-treatment – 1+ therapist from different disciplines working with 1 patient at same time  Group Therapy – one therapist to 2-6 patients performing same activity  Individual – one therapist to one patient at a time

Example  Prospective Payment System (PPS) for SNF Facility Prospective Payment System (PPS)  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  Prospective Payment System (PPS) for SNF Facility Prospective Payment System (PPS)  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  RAI Manual – Resident Assessment instrument RAI Manual  medicare/Medicare-Guidance-for-SLP-Services- in-Skilled-Nursing-Facilities/

Example  Hospital Outpatient Prospective Payment System Hospital Outpatient Prospective Payment System

Example  Outpatient Medicare Benefit Policy Manual Outpatient Medicare Benefit Policy Manual  Page  Certification/Recertification Plan of Care - Initial Plan of Care (within 30 days), and every 90 days following  Has to be signed by referral source  Progress Note – at least once every 10 th treatment day  Billing Scenarios for Medicare Part B Billing Scenarios

Skilled Care  CMS Update on Restorative Therapy and Maintenance Therapy CMS Update on Restorative Therapy and Maintenance Therapy

CPT Codes  Health Care Financing Administration Common Procedure Coding System  Uniform Coding System  Level I – CPT CodesCPT 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  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 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.

Fraudulent Behaviors  Billing for services not rendered  Billing for non-medically necessary treatment  Upcoding of services actually rendered

Healthcare Fraud and Abuse Control Program (HCFAC)Fraud and Abuse  Public Law (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 HCFAC Program Assessment

Office of Inspector General (OIG)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 2015 Work Plan OIG 2015 Work Plan

Ethics  SLP Code of Ethics SLP Code of Ethics  WELFARE of PERSONS SERVED  Shall not discriminate  Shall not charge for services not rendered  Example Example  Shall not discontinue services without reasonable notice

Ethics  PROFESSIONAL COMPETENCE  Engage in only those aspects of the professions that are within the scope of practice and individual competence

Ethics  RESPONSIBILITY TO THE PUBLIC  Shall not defraud in connection with payment, reimbursement, grants, research  Example Example

Ethics  RESPONSIBILITIES TO THE PROFESSION  Shall not engage in dishonesty, fraud, deceit, misrepresentation  Example Example

Documentation  Follow guidelines provided by  Board of Examiners –  National Association –  Insurance Companies/Payers  Aetna Clinical Policy Bulletin - Speech Aetna Clinical Policy Bulletin - Speech  Aetna Clinical Policy Bulletin – Voice Aetna Clinical Policy Bulletin – Voice  CMS CMS

Scope of Practice  Follow guidelines provided by  Board of Examiners –  National Association –

Class Assignment Prepare for class on Friday, March 13 th Bring a patient note to class