Reimbursement (Part Deux) L. Kay Garrison, PT, DPT

Managed Care Organizations Health Maintenance Organizations Managed Care Organizations

HMOs Around since 1960s- Nixon administration Members can access a panel of employed physicians or a network of doctors and facilities, including hospitals in exchange for fees Combines the financing and delivery of care for enrollees Patients have one PCP who must refer to specialists

Independent Practice Association (IPA) Type of HMO- based on capitation which is a set amount of $$$ for each person assigned to the physician/group Physicians can contract with multiple HMOs Can also accept fee-for-service from individuals

Preferred Provider Organization (PPO) Membership allows for significantly reduced rates vs. HMO Usually involves coinsurance vs. copayment The patient usually picks up more of the cost than with an HMO

Medicare For people 65 and older, with some exceptions for chronic renal disease, long term disability, and widows 50+ who are eligible for disability payments Funding comes from Social Security deductions

Medicare Part A Covers inpatient, SNFs, HHC, and hospice PT has to be delivered at a minimum of 5 days per week Therapy must be provided by a PT or a PTA under the supervision of a PT Must demonstrate FUNCTIONAL gain!!!!

Medicare Part B Covers MD visits, outpatient, some HHC, DME, medical supplies/equipment Requires 20% copayment Outpatient is usually covered 3x/week Does not cover services that promote overall fitness

Other Medicare programs Medicare Part C or Medicare + Choice is the Medicare HMO Medicare Part D is the prescription drug program

Private Health Insurance Most use Medicare as the gold standard Companies such as Aetna, Humana, CIGNA, BCBS, etc… May make their own requirements

Medicaid There is a wide degree of flexibility between states to determine eligibility- low income families/pregnant women, elderly/blind/on SS, high medical bills Federal gov’t matches state spending for medical/health services PT is considered optional

What you document determines what is reimbursed A few considerations….

Considerations Group treatment Overlapping “Dovetailing” Co-treatment Max units per day Billing for the same service as another provider Students “LPT only” Double chart

Lets look at some forms