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

2. Managed Care Organizations
Health Maintenance Organizations
Managed Care Organizations

3. 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

4. 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

5. 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

6. 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

7. 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!!!!

8. 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

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

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

11. 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

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

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

14. Lets look at some forms