1. Insurance Considerations Administration

2. Athletic Injury Insurance Terminology Premium Premium –What the insurance policy costs the individual(s) being covered, monthly or yearly UCR UCR –Usual, customary, and reasonable fees  Usual fee charged by each provider  Customary fee for area/geographic location –Average fee –90 th percentile fee –Whichever is lowest  Reasonable fee – the lower between usual and customary  Is procedure potentially labeled as “experimental?”

3. Athletic Injury Insurance 3 rd Party Reimbursement 3 rd Party Reimbursement –First and second parties are patient/medical provider –Third party is insurance company  The primary means for paying medical services in the nation Deductible Deductible –The amount owed by the insured on a per-incident basis before the insurance company will begin to pay for the services –Premium and deductible have inverse relationship Co-payments Co-payments –Percentage of a medical bill that is not covered by the insurance company and therefore must be covered by the individual or a secondary policy

4. What Does 3 rd Party Mean Anyway? – Three groups involved in determining an insurance program: Subscriber Subscriber – Individual or group of individuals being insured Provider (health care provider, facility) Provider (health care provider, facility) – Providing the service to the subscriber Insurance company (3 rd party) Insurance company (3 rd party) – Responsible for setting fee structures with providers, paying bills for the subscriber, and determining the benefits to be paid

5. ICD-9 Internal Classification of Diseases Internal Classification of Diseases ICD-10 effective Oct 1, 2014 ICD-10 effective Oct 1, 2014 Coding used to standardize the classification of illness, injury, conditions Coding used to standardize the classification of illness, injury, conditions Used for consistency among third parties Used for consistency among third parties Examples Examples

6. CPT codes Current Procedural Terminology Current Procedural Terminology Codes used for Codes used forproceduresperformed -Modalities, exercises Examples

7. Managed Care Organization MCO MCO –Umbrella term including  Health Maintenance Organization (HMO)  Preferred Provider Organization (PPO)  Exclusive provider organization (EPO)  Point of service (POS)  Too much alphabet soup?

8. Health Maintenance Organization HMO HMO –Policy requiring policyholders to only use providers approved by the company –Primary care physician/provider – acts as gatekeeper and everything must be referred by/through them

9. Preferred Provider Organization PPO PPO –Allows greater freedom in choosing providers, but provides financial incentives for choosing providers within their “network”  May pay 100% for “in network” physicians, but only 80% for “out of network” physicians.

10. Health Savings Account (HSA) Uniquely arranged from company to company Uniquely arranged from company to company Design similar to PPO Design similar to PPO Funded by individuals or employer groups Funded by individuals or employer groups The HSA decides what types of coverage will be provided, negotiates with providers toward this end The HSA decides what types of coverage will be provided, negotiates with providers toward this end

11. Medicare/CMS Federal program Federal program Provides health insurance to retired individuals, regardless of their medical conditions Provides health insurance to retired individuals, regardless of their medical conditions Age 65 is the usual qualifying age Age 65 is the usual qualifying age

12. Medicaid/CMS – For people with low income – Joint federal-state program (state administered) – Two eligibility requirements: Fall below certain income limits Fall below certain income limits Be within an eligible group: Be within an eligible group: – Aged – Disabled – Blind – Needy, dependent children

13. Medicaid – Broad federal guidelines – States determine Eligibility requirements Eligibility requirements Amount, duration, types of service Amount, duration, types of service Rate of reimbursement Rate of reimbursement Oversight of program Oversight of program

14. Strategies to Minimize Cost to School or School’s Insurance Mandating Primary Insurance Mandating Primary Insurance –Increasing popularity –Problem: Some students do not have insurance –Problem: Some insurances (HMO, PPO) may not cover the athlete at the school

15. Strategies to Minimize Cost to School or School’s Insurance Adjusting the PCP Adjusting the PCP –If possible, change the student’s PCP to a campus physician; to make the college resources in-network –Some insurances allow exemptions for out-of- network issues Negotiating Fees With Providers Negotiating Fees With Providers –The school negotiates fees for commonly used services

16. Strategies to Minimize Cost to School or School’s Insurance Timely and Accurate Claim Filing Timely and Accurate Claim Filing – Complete notification of injury form – File a CMS 1500/UB-92 claim form to primary insurance – Insurance provides payment – Athlete receives explanation of benefits (EOB) from insurance – Send notification of injury form, CMS 1500, and EOB to secondary insurance – Secondary insurance/third-party administrator (TPA) pays any due to the provider

17. Reimbursement for Services Provided Reimbursement for AT Services Traditionally done in the clinic setting Traditionally done in the clinic setting Recently, all types of settings have become involved in this process Recently, all types of settings have become involved in this process The state’s practice act will aid/hinder the ability of reimbursement for services The state’s practice act will aid/hinder the ability of reimbursement for services

18. Reimbursement for Services Provided Direct Compensation (cash pay) Direct Compensation (cash pay) –Payment comes directly from the individual receiving service –Often found when extra services are not covered by insurance Third-Party Reimbursement Third-Party Reimbursement –Compensated for a service from someone other than the patient –Typically an insurance company

19. Reimbursement for Services Provided Obtaining Reimbursement From an Insurance Company Obtaining Reimbursement From an Insurance Company –Must have an established “medical necessity” Type and frequency of care Type and frequency of care Usually in the form of a physician letter Usually in the form of a physician letter Person providing intervention must be recognized as “capable” of providing the outlined care and have an established fee structure Person providing intervention must be recognized as “capable” of providing the outlined care and have an established fee structure –Some insurance groups do not yet recognize athletic trainers in this way –Goes back to practice act –Pending WI legislation

20. Reimbursement for Services Provided –National Provider Identifier (NPI) number – Needed to bill for services Technically only needed for services recognized by the Center for Medicaid and Medicare Services (CMS) Technically only needed for services recognized by the Center for Medicaid and Medicare Services (CMS) Despite athletic trainers not currently treating Medicare, insurance companies look to CMS for standards for which to provide reimbursement Despite athletic trainers not currently treating Medicare, insurance companies look to CMS for standards for which to provide reimbursement –Referral for “athletic training” services –Our ability to fight for more reimbursement hinges on % of ATs with NPI

21. Fee for Service Plan Indemnity plan Indemnity plan Policy covers a portion of the procedure, regardless of who does it or where its done Policy covers a portion of the procedure, regardless of who does it or where its done Patient is responsible for covering the balance of the bill Patient is responsible for covering the balance of the bill Not very common, HMO/PPO most common Not very common, HMO/PPO most common

22. Exclusive Provider Organization EPO EPO Structured the same as PPO, except if an out of network provider is used, the patient is responsible for the entire cost, not just partial. Structured the same as PPO, except if an out of network provider is used, the patient is responsible for the entire cost, not just partial.

23. Point of Service POS POS –Combination of HMO and PPO –Similar to PPO except in the way the provider is reimbursed –Reverts to a fee for service method if an out of network provider is used

24. Explanation of Benefits EOB EOB –Description of how the benefits were paid – verifies which medical bills the insurance company paid and whether there was third party reimbursement, or reimbursement to the patient/parents –This form must be sent to policy holder EVERY time there is a claim

25. Professional Liability Insurance A type of insurance that covers claims of negligence on the part of individuals A type of insurance that covers claims of negligence on the part of individuals Recommended very highly for athletic trainers – students? Recommended very highly for athletic trainers – students? –Some camps and internships may require this? What might not get covered under employer’s liability? What might not get covered under employer’s liability? –Does your employer even have a liability plan?  Might be something you need to ask Examples… Examples… http://www.hpso.com/ http://www.hpso.com/ http://www.hpso.com/ NATA discount - https://www.personal- plans.com/nata/benefits/plan.do;itgJSessionID=p8LjN44JQGNjSx1 bTLWtyJWTKJjz9NHkCg3wl1rVHQTdznfnRQ7Z!67493463?planID= 3006 NATA discount - https://www.personal- plans.com/nata/benefits/plan.do;itgJSessionID=p8LjN44JQGNjSx1 bTLWtyJWTKJjz9NHkCg3wl1rVHQTdznfnRQ7Z!67493463?planID= 3006https://www.personal- plans.com/nata/benefits/plan.do;itgJSessionID=p8LjN44JQGNjSx1 bTLWtyJWTKJjz9NHkCg3wl1rVHQTdznfnRQ7Z!67493463?planID= 3006https://www.personal- plans.com/nata/benefits/plan.do;itgJSessionID=p8LjN44JQGNjSx1 bTLWtyJWTKJjz9NHkCg3wl1rVHQTdznfnRQ7Z!67493463?planID= 3006

27. Conference Topics Conference on Revenue and Business of AT The current reimbursement climate Demonstrating value/revenue potential Reimbursement models for a wide variety of settings Documentation and billing/coding Approaching insurance companies/addressing denials Preparing the young professional for the business of AT Overcoming administrative hurdles Networking and building relationships

28. Functional Outcome Results

29. 29 “I never learned anything from a match I won.” Bobby Jones

30. Demonstrating Value How to demonstrate value? How to demonstrate value? Third party reimbursement Third party reimbursement Fee for service revenue Fee for service revenue Downstream referral revenue Downstream referral revenue Patient and athlete satisfaction Patient and athlete satisfaction Quality and safety improvement Quality and safety improvement Customer service improvement Customer service improvement Throughput increases Throughput increases Public relations and marketing Public relations and marketing NATA News article NATA News article

31. Marketing/PR

32. Insurance Assignment Handout Handout Due before Thanksgiving (Tues 11/22) Due before Thanksgiving (Tues 11/22)