© 2006 McGraw-Hill Higher Education. All rights reserved. Athletic Training Management Chapter 11...

© 2006 McGraw-Hill Higher Education. All rights © 2006 McGraw-Hill Higher Education. All rights reserved. reserved.

Athletic Training Athletic Training ManagementManagement

Chapter 11 Chapter 11

Third Party ReimbursementThird Party ReimbursementEdited by Jeff Konin, Ph.D., Edited by Jeff Konin, Ph.D.,

ATC, MPTATC, MPT


AT and 3AT and 3rdrd party party ReimbursementReimbursement

Athletic training has its own CPT code and Athletic training has its own CPT code and can already bill for servicescan already bill for services– Only effective if insurance will payOnly effective if insurance will pay– Many third party payers are not familiar with Many third party payers are not familiar with

athletic trainingathletic training– We do NOT have a Medicare billing clearanceWe do NOT have a Medicare billing clearance

Many insurance companies follow Medicare’s leadMany insurance companies follow Medicare’s lead

– Claims my be rejected for any number of Claims my be rejected for any number of reasons (see table 11.1)reasons (see table 11.1)


Importance of BillingImportance of Billing33rdrd party reimbursement represents party reimbursement represents acceptance of the profession as an allied acceptance of the profession as an allied healthcare professionhealthcare profession– It is a means to offering enhanced professional It is a means to offering enhanced professional

recognition, job security, and wage improvementsrecognition, job security, and wage improvements

Income generated pays your salary and Income generated pays your salary and benefitsbenefits– While not every service is billed in all settings at While not every service is billed in all settings at

this time, successful billing has occurred in all this time, successful billing has occurred in all settingssettings


Importance of BillingImportance of Billing

May be a potential income source in May be a potential income source in college, pro, and high school settingscollege, pro, and high school settings

With ever increasing costs in athletic With ever increasing costs in athletic departments, the need for 3departments, the need for 3rdrd party party reimbursement is growingreimbursement is growing– Can add budget stability to an athletic Can add budget stability to an athletic

program rather than be a drainprogram rather than be a drain

Many athletic trainers are reluctant to bill Many athletic trainers are reluctant to bill as an ethical issueas an ethical issue


Importance of BillingImportance of Billing

– It is important to remember that all services It is important to remember that all services are already billed, the bill is paid by athletics, are already billed, the bill is paid by athletics, usually in advance, but still paidusually in advance, but still paid

Generating revenue for services provided Generating revenue for services provided may help off-set management concern for may help off-set management concern for elevating salarieselevating salaries


What is a Third-Party PayerWhat is a Third-Party PayerThe patient is the first party, the medical The patient is the first party, the medical professional the second party and the professional the second party and the insurance carrier the third partyinsurance carrier the third party

Traditional insurance like BC/BS, Aetna, Traditional insurance like BC/BS, Aetna, Mutual of Omaha, etc.Mutual of Omaha, etc.

Managed Care OrganizationsManaged Care Organizations– Groups of either defined providers or customers Groups of either defined providers or customers

or both to give access and manage health care or both to give access and manage health care costscosts

– See Chapter 10See Chapter 10


Reimbursement CodesReimbursement Codes

Basic information is submitted in a Basic information is submitted in a standardized coding format so that proper standardized coding format so that proper processing can occurprocessing can occur

Codes representing the diagnosis of a Codes representing the diagnosis of a problem are according to the International problem are according to the International Classification of Diseases (ICD)Classification of Diseases (ICD)

Codes documenting treatment procedures Codes documenting treatment procedures are Current Procedural Terminology (CPT) are Current Procedural Terminology (CPT) codes or universal billing (UB) codescodes or universal billing (UB) codes



The treatment intervention must always The treatment intervention must always match the intervention code in order for a match the intervention code in order for a 33rdrd party to pay party to pay

For 3For 3rdrd party payers the CPT or UB codes party payers the CPT or UB codes are matched to the ICD codes to ensure are matched to the ICD codes to ensure appropriate interventionsappropriate interventions



International Classification of Disease International Classification of Disease codes (ICD) tell the insurer the specific codes (ICD) tell the insurer the specific diagnosisdiagnosis– Any service provider would use the same Any service provider would use the same

code for the same conditioncode for the same condition– Used to determine appropriateness of the Used to determine appropriateness of the

procedures delineated by CPT codeprocedures delineated by CPT code



– 845 – Sprains and strains of the foot and ankle845 – Sprains and strains of the foot and ankle– 845.0 – ankle845.0 – ankle– 845.00 – unspecified site845.00 – unspecified site– 845.01 – deltoid (ligament), ankle845.01 – deltoid (ligament), ankle– 845.02 – calcaneofibular (ligament)845.02 – calcaneofibular (ligament)– 845.03 – tibiofibular (ligament), distal845.03 – tibiofibular (ligament), distal– 845.09 – other845.09 – other– 845.1 – foot845.1 – foot– 845.10 – unspecified site845.10 – unspecified site– etc.etc.



DRG codesDRG codes– Diagnostic-related group is a system of Diagnostic-related group is a system of

classification used by Medicare and other classification used by Medicare and other insurers to classify illnesses according to insurers to classify illnesses according to diagnosis and treatmentdiagnosis and treatment

– Fixed amounts of payment are assigned to Fixed amounts of payment are assigned to each DRG in ADVANCE and paid on a per-each DRG in ADVANCE and paid on a per-case basiscase basis

– Originally designed for acute hospital careOriginally designed for acute hospital care


Reimbursement CodesReimbursement CodesCPT codesCPT codes– Current Procedural Terminology codes are Current Procedural Terminology codes are

developed by the AMA Department of Coding developed by the AMA Department of Coding and Nomenclatureand Nomenclature

– Provider as defined in CPT codes is anyone Provider as defined in CPT codes is anyone who is licensed to provide serviceswho is licensed to provide services

– Therapist is a generic term and refers to no Therapist is a generic term and refers to no specific professionspecific profession

Payment is often decided not on the type of Payment is often decided not on the type of therapist, but on whether or not the therapist is therapist, but on whether or not the therapist is licensed or approved to perform the interventionlicensed or approved to perform the intervention


Reimbursement CodesReimbursement Codes– 97005 – athletic trainer evaluation97005 – athletic trainer evaluation– 97006 – athletic trainer reevaluation97006 – athletic trainer reevaluation– 97010 – application of modality to one or more areas; hot 97010 – application of modality to one or more areas; hot

or cold packsor cold packs– 97012 – traction, mechanical97012 – traction, mechanical– 97014 – electrical stimulation (unattended)97014 – electrical stimulation (unattended)– 97016 – vasopneumatic devices97016 – vasopneumatic devices– 97018 – paraffin bath97018 – paraffin bath– 97020 – microwave97020 – microwave– 97022 – whirlpool97022 – whirlpool– 97024 – diathermy97024 – diathermy– 97032 – electrical stimulation (one-on-one) for trigger point97032 – electrical stimulation (one-on-one) for trigger point



– 97033 – iontophoresis (each 15 min)97033 – iontophoresis (each 15 min)– 97035 – ultrasound97035 – ultrasound– 97110 – therapeutic exercise (each 15 min)97110 – therapeutic exercise (each 15 min)– 97116 – gait training (each 15 min)97116 – gait training (each 15 min)– 97124 – massage (each 15 min)97124 – massage (each 15 min)– 97139 – taping general97139 – taping general– 29280 – hand/finger strapping/taping29280 – hand/finger strapping/taping– 29530 – knee strapping/taping29530 – knee strapping/taping– 29540 – ankle strapping/taping29540 – ankle strapping/taping– etc.etc.



Universal Billing (UB) code are similar to Universal Billing (UB) code are similar to CPT codes and used in hospitalsCPT codes and used in hospitals


Preparing DocumentationPreparing Documentation

– Documents should be developed providing Documents should be developed providing accurate comprehensive information about a accurate comprehensive information about a patient’s condition and treatment intervention patient’s condition and treatment intervention and that conforms to the requirements of 3and that conforms to the requirements of 3 rdrd party payersparty payers

– Minimum needs include patient registration Minimum needs include patient registration form, a patient encounter form (fig 11-1), a form, a patient encounter form (fig 11-1), a daily journal, an individual patient’s accounts daily journal, an individual patient’s accounts form, a treatment note, and insurance claims form, a treatment note, and insurance claims forms (fig 11-2 HCFA- 1500 and UB-92)forms (fig 11-2 HCFA- 1500 and UB-92)


Filing a ClaimFiling a Claim

First determine whether the patient or you First determine whether the patient or you will file the formswill file the forms– Find out from the payer if you must be assigned Find out from the payer if you must be assigned

a provider numbera provider number– They will tell you how to file a claim with themThey will tell you how to file a claim with them– Review the patient’s policy to determine what is Review the patient’s policy to determine what is

coveredcovered– Be sure to inform patients that they are Be sure to inform patients that they are

ultimately responsible for the billultimately responsible for the bill– Physician referral is often required to be Physician referral is often required to be

reimbursedreimbursed


Filing a ClaimFiling a Claim

– Obtain necessary claim formsObtain necessary claim forms– You will need to indicate the physician You will need to indicate the physician

diagnosis and the treatment provideddiagnosis and the treatment providedUse ICD-9-CM and CPT or UB codesUse ICD-9-CM and CPT or UB codes

Correct coding is essentialCorrect coding is essential

Filing for managed care organizations is similar to Filing for managed care organizations is similar to non-managed carenon-managed care

– Communication with the carrier is essentialCommunication with the carrier is essential– Use of the required forms is essentialUse of the required forms is essential


Submitting the ClaimSubmitting the Claim

Can be submitted either in written or Can be submitted either in written or electronic formelectronic form

Trend is electronic to speed filing and Trend is electronic to speed filing and decrease the paper traildecrease the paper trail

Completeness and accuracy is a mustCompleteness and accuracy is a must

Missing, inaccurate, or incomplete data, or Missing, inaccurate, or incomplete data, or data not conforming to the electronic data not conforming to the electronic billing system will cause denialbilling system will cause denial


Handling Denied ClaimsHandling Denied Claims

Go back and review the patient’s policy to Go back and review the patient’s policy to reestablish patient’s coverage limitationsreestablish patient’s coverage limitations

Write an appeal letter if the service should Write an appeal letter if the service should be coveredbe covered– Include any new data that supports the claimInclude any new data that supports the claim– It they still refuse, consider referring the It they still refuse, consider referring the

patient to small claims courtpatient to small claims court– Also file a complaint with the state insurance Also file a complaint with the state insurance

commissionercommissioner



– The appeal letter should include the following The appeal letter should include the following information:information:

Facility information (name, address, phone)Facility information (name, address, phone)

Date of appealDate of appeal

Reminder of original date of claims submissionReminder of original date of claims submission

Recipient’s name and addressRecipient’s name and address

Provider information (name, address, provider Provider information (name, address, provider number, tax number)number, tax number)

Patient information (name, address, phone, insurer Patient information (name, address, phone, insurer identification number)identification number)

Date of service and total chargesDate of service and total charges



Claim numberClaim number

Reiteration of the reason for denialReiteration of the reason for denial

Explanation of why charges should be paidExplanation of why charges should be paid


Communicating with PayersCommunicating with Payers

Many insurers will have no experience Many insurers will have no experience with athletic trainerswith athletic trainers

You may need to provide the necessary You may need to provide the necessary information on education, licensure, information on education, licensure, certification status, etc.certification status, etc.

If you are communicating over a denied If you are communicating over a denied claim for reasons other than if you are an claim for reasons other than if you are an eligible provider, method of eligible provider, method of communications is importantcommunications is important


Communicating with PayersCommunicating with Payers

Communications should be direct, use Communications should be direct, use practical and functional terms, and practical and functional terms, and universally understood medical universally understood medical terminologyterminology

You may have to explain grading systems You may have to explain grading systems for various conditionsfor various conditions

You should always document the names, You should always document the names, dates, and times with whom you spokedates, and times with whom you spoke


Challenges to Third-Party Challenges to Third-Party ReimbursementReimbursement

Because athletic training is not Because athletic training is not credentialed in all 50 states, it is necessary credentialed in all 50 states, it is necessary for athletic trainers to demonstrate to for athletic trainers to demonstrate to payers the worthiness for paymentpayers the worthiness for paymentAs long as the athletic trainer meets the As long as the athletic trainer meets the same requirements as other reimbursable same requirements as other reimbursable providers that were set up by a 3providers that were set up by a 3rdrd party party payer, within both federal and state law payer, within both federal and state law and scope of practice, reimbursement and scope of practice, reimbursement should be possibleshould be possible


Challenges to Third-Party Challenges to Third-Party ReimbursementReimbursement

Payers may ask for any of the following Payers may ask for any of the following when determining reimbursementwhen determining reimbursement– Is athletic training regulated by the stateIs athletic training regulated by the state– Is the service within you scope of practiceIs the service within you scope of practice– If athletic training is not regulated at the state If athletic training is not regulated at the state

level, is there a national credential such as level, is there a national credential such as certificationcertification

– Are you providing service within the scope of Are you providing service within the scope of certificationcertification

© 2006 McGraw-Hill Higher Education. All rights reserved. Athletic Training Management Chapter 11...

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Transcript of © 2006 McGraw-Hill Higher Education. All rights reserved. Athletic Training Management Chapter 11...