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© 2006 McGraw-Hill Higher Education. All rights reserved. Athletic Training Management Chapter 11 Third Party Reimbursement Edited by Jeff Konin, Ph.D., ATC, MPT
© 2006 McGraw-Hill Higher Education. All rights reserved. AT and 3 rd party Reimbursement Athletic training has its own CPT code and can already bill for services –Only effective if insurance will pay –Many third party payers are not familiar with athletic training –We do NOT have a Medicare billing clearance Many insurance companies follow Medicares lead –Claims my be rejected for any number of reasons (see table 11.1)
© 2006 McGraw-Hill Higher Education. All rights reserved. Importance of Billing 3 rd party reimbursement represents acceptance of the profession as an allied healthcare profession –It is a means to offering enhanced professional recognition, job security, and wage improvements Income generated pays your salary and benefits –While not every service is billed in all settings at this time, successful billing has occurred in all settings
© 2006 McGraw-Hill Higher Education. All rights reserved. Importance of Billing May be a potential income source in college, pro, and high school settings With ever increasing costs in athletic departments, the need for 3 rd party reimbursement is growing –Can add budget stability to an athletic program rather than be a drain Many athletic trainers are reluctant to bill as an ethical issue
© 2006 McGraw-Hill Higher Education. All rights reserved. Importance of Billing –It is important to remember that all services are already billed, the bill is paid by athletics, usually in advance, but still paid Generating revenue for services provided may help off-set management concern for elevating salaries
© 2006 McGraw-Hill Higher Education. All rights reserved. What is a Third-Party Payer The patient is the first party, the medical professional the second party and the insurance carrier the third party Traditional insurance like BC/BS, Aetna, Mutual of Omaha, etc. Managed Care Organizations –Groups of either defined providers or customers or both to give access and manage health care costs –See Chapter 10
© 2006 McGraw-Hill Higher Education. All rights reserved. Reimbursement Codes Basic information is submitted in a standardized coding format so that proper processing can occur Codes representing the diagnosis of a problem are according to the International Classification of Diseases (ICD) Codes documenting treatment procedures are Current Procedural Terminology (CPT) codes or universal billing (UB) codes
© 2006 McGraw-Hill Higher Education. All rights reserved. Reimbursement Codes The treatment intervention must always match the intervention code in order for a 3 rd party to pay For 3 rd party payers the CPT or UB codes are matched to the ICD codes to ensure appropriate interventions
© 2006 McGraw-Hill Higher Education. All rights reserved. Reimbursement Codes International Classification of Disease codes (ICD) tell the insurer the specific diagnosis –Any service provider would use the same code for the same condition –Used to determine appropriateness of the procedures delineated by CPT code
© 2006 McGraw-Hill Higher Education. All rights reserved. Reimbursement Codes –845 – Sprains and strains of the foot and ankle –845.0 – ankle –845.00 – unspecified site –845.01 – deltoid (ligament), ankle –845.02 – calcaneofibular (ligament) –845.03 – tibiofibular (ligament), distal –845.09 – other –845.1 – foot –845.10 – unspecified site –etc.
© 2006 McGraw-Hill Higher Education. All rights reserved. Reimbursement Codes DRG codes –Diagnostic-related group is a system of classification used by Medicare and other insurers to classify illnesses according to diagnosis and treatment –Fixed amounts of payment are assigned to each DRG in ADVANCE and paid on a per- case basis –Originally designed for acute hospital care
© 2006 McGraw-Hill Higher Education. All rights reserved. Reimbursement Codes CPT codes –Current Procedural Terminology codes are developed by the AMA Department of Coding and Nomenclature –Provider as defined in CPT codes is anyone who is licensed to provide services –Therapist is a generic term and refers to no specific profession Payment is often decided not on the type of therapist, but on whether or not the therapist is licensed or approved to perform the intervention
© 2006 McGraw-Hill Higher Education. All rights reserved. Reimbursement Codes –97005 – athletic trainer evaluation –97006 – athletic trainer reevaluation –97010 – application of modality to one or more areas; hot or cold packs –97012 – traction, mechanical –97014 – electrical stimulation (unattended) –97016 – vasopneumatic devices –97018 – paraffin bath –97020 – microwave –97022 – whirlpool –97024 – diathermy –97032 – electrical stimulation (one-on-one) for trigger point
© 2006 McGraw-Hill Higher Education. All rights reserved. Reimbursement Codes –97033 – iontophoresis (each 15 min) –97035 – ultrasound –97110 – therapeutic exercise (each 15 min) –97116 – gait training (each 15 min) –97124 – massage (each 15 min) –97139 – taping general –29280 – hand/finger strapping/taping –29530 – knee strapping/taping –29540 – ankle strapping/taping –etc.
© 2006 McGraw-Hill Higher Education. All rights reserved. Reimbursement Codes Universal Billing (UB) code are similar to CPT codes and used in hospitals
© 2006 McGraw-Hill Higher Education. All rights reserved. Preparing Documentation –Documents should be developed providing accurate comprehensive information about a patients condition and treatment intervention and that conforms to the requirements of 3 rd party payers –Minimum needs include patient registration form, a patient encounter form (fig 11-1), a daily journal, an individual patients accounts form, a treatment note, and insurance claims forms (fig 11-2 HCFA- 1500 and UB-92)
© 2006 McGraw-Hill Higher Education. All rights reserved. Filing a Claim First determine whether the patient or you will file the forms –Find out from the payer if you must be assigned a provider number –They will tell you how to file a claim with them –Review the patients policy to determine what is covered –Be sure to inform patients that they are ultimately responsible for the bill –Physician referral is often required to be reimbursed
© 2006 McGraw-Hill Higher Education. All rights reserved. Filing a Claim –Obtain necessary claim forms –You will need to indicate the physician diagnosis and the treatment provided Use ICD-9-CM and CPT or UB codes Correct coding is essential Filing for managed care organizations is similar to non-managed care –Communication with the carrier is essential –Use of the required forms is essential
© 2006 McGraw-Hill Higher Education. All rights reserved. Submitting the Claim Can be submitted either in written or electronic form Trend is electronic to speed filing and decrease the paper trail Completeness and accuracy is a must Missing, inaccurate, or incomplete data, or data not conforming to the electronic billing system will cause denial
© 2006 McGraw-Hill Higher Education. All rights reserved. Handling Denied Claims Go back and review the patients policy to reestablish patients coverage limitations Write an appeal letter if the service should be covered –Include any new data that supports the claim –It they still refuse, consider referring the patient to small claims court –Also file a complaint with the state insurance commissioner
© 2006 McGraw-Hill Higher Education. All rights reserved. Handling Denied Claims –The appeal letter should include the following information: Facility information (name, address, phone) Date of appeal Reminder of original date of claims submission Recipients name and address Provider information (name, address, provider number, tax number) Patient information (name, address, phone, insurer identification number) Date of service and total charges
© 2006 McGraw-Hill Higher Education. All rights reserved. Handling Denied Claims Claim number Reiteration of the reason for denial Explanation of why charges should be paid
© 2006 McGraw-Hill Higher Education. All rights reserved. Communicating with Payers Many insurers will have no experience with athletic trainers You may need to provide the necessary information on education, licensure, certification status, etc. If you are communicating over a denied claim for reasons other than if you are an eligible provider, method of communications is important
© 2006 McGraw-Hill Higher Education. All rights reserved. Communicating with Payers Communications should be direct, use practical and functional terms, and universally understood medical terminology You may have to explain grading systems for various conditions You should always document the names, dates, and times with whom you spoke
© 2006 McGraw-Hill Higher Education. All rights reserved. Challenges to Third-Party Reimbursement Because athletic training is not credentialed in all 50 states, it is necessary for athletic trainers to demonstrate to payers the worthiness for payment As long as the athletic trainer meets the same requirements as other reimbursable providers that were set up by a 3 rd party payer, within both federal and state law and scope of practice, reimbursement should be possible
© 2006 McGraw-Hill Higher Education. All rights reserved. Challenges to Third-Party Reimbursement Payers may ask for any of the following when determining reimbursement –Is athletic training regulated by the state –Is the service within you scope of practice –If athletic training is not regulated at the state level, is there a national credential such as certification –Are you providing service within the scope of certification
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