Third Party Reimbursement in Athletic Training Kolton Hawkins Jacob Ritchey Dakota Shirar

3 rd Party Reimbursement 3 rd party reimbursement is the primary mechanism of payment for health care professionals. Reimbursement is by the policyholder’s insurance company for medical services preformed.

Payers Who else pays?  The patient is the first party.  The medical professional is the second party.  The insurance carrier the third party.

Reimbursement Advisory Group  In 1995, NATA established this group to help athletic trainers secure a place as a health care professional.  This group was also charged with approaching third party payers for reimbursement.

Legislation  In Indiana, there are 3 sections of legislation regarding of 3 rd party reimbursement of athletic trainers.  This law went into effect July 1 st 2011.

Section 1  Section 1 of HEA 1467 will require insurers that cover physical medicine and rehabilitative services to cover those services if they are provided by a LAT within the LAT scope of practice. Importantly, the law will not require insurers to cover all LAT services. Instead, the law takes away the ability of an insurer to refuse to cover services provided by LATs, if the insurer covers those services generally and the services fall within the LAT scope of practice.

Section 2  Section 2 of HEA 1467 will add LAT services to the list of health care services potentially covered by HMOs. Once effective, this means that LATs may go through the credentialing process to become a participating provider. Note, as discussed in the Limitations section below, the language of HEA 1467 will not require HMOs to credential any willing LAT.

Section 3  Section 3 of HEA 1467 specifies that Sections 1 and 2 only apply to plans and contracts issued, delivered, amended or renewed on or after July 1, Section 3 will expire on July 1, By this date, all existing plans will have been renewed and thus will have come under the requirements of the law. The mandates of Section 1 and 2 will continue beyond 2015.

Third-Party Payers  This group of third party payers includes a number of insurance plans and organizations.  Health Maintenance Organizations (HMO), Preferred Provider organizations (PPO), Point of Service Plan (POS), Exclusive Provider Organizations (EPO), Physician Hospital Organization (PHO), Third-Party Administrators (TPA), Medicare, Medicaid, Workers Compensation, Indemnity Plans, and Capitation

Health Maintenance Organizations (HMO)  Pay 100% if its at a HMO facility  Some fees may be applied for treatment elsewhere using a capitation system  Provides mostly preventive measures  Must obtain permission, unless an emergency  Limits where individual receives care  Athletic Trainers must understand the restrictions with this organization.  Here’s a more detailed explanation of HMO

Preferred Provider Organizations (PPO)  Discount healthcare program  Limits where individual receives care  Fees may be applied for unapproved locations  Pay on a fee-for-service basis  Athletic trainers must understand restrictions with this organization.

Point of Service Plan (POS)  HMO structure  Flexibly allows services outside HMO  Only under special conditions

Exclusive Provider Organizations (EPO)  Combines HMO and PPO  More like HMO  Restricted number and types of providers  May not pay at all if using out-of-network providers

Physician Hospital Organization (PHO)  Major hospital or chains  Own physicians  Contracts with employers

Third-Party Administrators (TPA)  Frequently used  Administer service and pay claims  Pseudo insurance companies

Medicare  Government funded  For elderly and disabled  Multiple parts -A. Hospital portion, premium-free at retirement -B. Physician care, monthly premium charge -C. Wide variety of health care plans -D. Helps with prescription drugs  Since 2005, Medicare does not cover Athletic Trainers in Third-Party Reimbursement. Here is a video to further explain the parts of Medicare

Medicaid  For people with low income or limited resources  Funded by the federal and states government  Benefits may vary by state  Since 2005, Medicaid does not cover Athletic Trainers in Third-Party Reimbursement.

Workers Compensation  Laws and benefits for injured workers  Mandated by states  Employers pay premium  Main goal is to return employees to workforce immediately

Indemnity Plans  Most traditional  Fee-for-service  Seek care without restriction

Capitation  Members make standard payments each month, regardless of how much is used.

What is a claim?  A claim is a demand for payment in accordance with an insurance with an insurance policy.

Insurance Billing  Must fill out claims immediately and correctly  Must have medical documentation on the patient.  When working in a school setting the athletic trainer should collect every athletes insurance  When working in a clinic or hospital the athletic trainer must make sure that the patient is showing current insurance.  the athletic trainer should request approval from the insurance company before treating.

Documentation and Claim Guidelines 1. Must be legible and complete 2. Each patient’s documented record should include: a. The reason for this encounter and any relevant history, any physical examinations and findings, any prior test results. b. The diagnosis, assessment and clinical impressions c. The plan of care and treatment d. Date of service and clear identity of the provider

3. The reason for ordering any testing or diagnostic procedures should be documented 4. Current as well as past diagnoses should be accessible to the treating or consulting provider 5. Health risk factors should be identified and noted 6. The patient’s response to treatment, notes on any changes in treatment, the patient’s progress or lack of and any revisions in diagnosis should also be documented 7. The CPT, ICD 9-CM and HCPCS codes listed and billed to third party payers on the claim form should be supported by the documentation contained in the medical record. Continued…

 TABLE 3–1Description of Billing Codes Used by Athletic Trainers  97005/97006 Athletic trainer evaluation and reevaluation (per visit)  Physical performance test (each 15 minutes) treatment charges  Gait training (each 15 minutes)  Therapeutic exercise (each 15 minutes)  Neuromuscular reeducation (each 15 minutes)  Therapeutic activities (each 15 minutes)  Aquatic therapeutic exercise (each 15 minutes)  Massage (each 15 minutes)  Body mechanics training (each 15 minutes)  Manual therapy (each 15 minutes)  Orthotics fitting and training (each 15 minutes)  Therapeutic procedures—group (each visit)  Supervised exercise (each visit)  Debridement (each visit)  Wound care (each 15 minutes)  Taping (each visit) Codes

Sources  Konin, Jeff. “Athletic Training Management” McGraw- Hill Connect; 2009  NATA.. Strategies for Approaching 3rd Party Payers Available at resources/reimbursement/third-party-payers.  Prentice, William. “Principles of Athletic Training” New York City: The McGraw-Hill Company; 2009  Taylor, Allson. “New Law Affecting Coverage of Certain Athletic Training Services.” Indianapolis, IN: Hall Render Killian Heath & Lyman; 2011  Watkins, Jennifer. “Status of Third Party Reimbursement for Athletic Trainers in Indiana” Muncie, IN; Ball State University; 2009