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Reimbursement: Surviving Prospective Payment as an RT Practitioner

Reimbursement: Surviving Prospective Payment as an RT Practitioner. Chapter 19 – Part 2 HPR 453. Evolution of Payment and Coverage. Fee for service Provider controls price – bartering for services in “old days” Boom time for hospitals and healthcare

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Reimbursement: Surviving Prospective Payment as an RT Practitioner

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  1. Reimbursement: Surviving Prospective Payment as an RT Practitioner Chapter 19 – Part 2 HPR 453

  2. Evolution of Payment and Coverage • Fee for service • Provider controls price – bartering for services in “old days” • Boom time for hospitals and healthcare • Less frequent today – managed care has replaced to cut costs • Implications for RT • Manager must understand system to account for every $ • Tx and services must show outcomes

  3. Examples in RT can be found but vary across the country due to lack of knowledge, misinterpretations of guidelines or resistance to change • Discounted Fee for Service • Negotiating price-setting process between provider and payer • Can be accomplished as identification of a provider and assurance of increased business

  4. Implications for RT • Must have fee-for-service system in place • RT has traditionally lower direct cost so can maintain a reasonable net margin • Using group procedures with reasonable expectation of improving patient’s condition using a group design • Example – Aquatic Therapy for a school district • # of pts, duration of tx, Frequency of tx, school personnel assistance with pre and post-pool functions, presence of school personnel in pool

  5. Per Diem • Daily charge vs. charge per procedure • Fee for service is ordering from menu…Per Diem is eating the buffet • Implications for RT • Increased emphasis on interdisciplinary team • Coordination to avoid duplication of services • Cost-effective mix of tx services • Education for inclusion of RT as covered service is critical for service manager • Licensed skilled nursing settings are driven by Medicare and Medicade per diem reimbursement

  6. Capitated Per Diem • Under per diem if you couldn’t charge more per day then increase the days • Capitated per diem maintains daily charge with limit on number of days • Implications for RT • Quicker results to move patient to next level of care are valued • RT examples • Medicare partial hospitalization • Long-Term care (100 skilled nursing facility days) • If RT is employed in these 2 settings, cost assumed under per diem amount

  7. Prospective Payment of Care • Predetermined amount of payment calculated on historical or statistical costs • First occurred with DPGs • Expanded version of per diem (per day) to per episode (acute care stay or comprehensive rehab discharge) • Classifies pts into groups for payment • Implications for RT • Expanded access for RT because it is bundled care for rehab svcs – RT is a primary rehab svc

  8. Examples of RT Payment • Under FPP leadership of ATRA, the profession has received special recognition as a qualified service to satisfy 3-hr rule in comprehensive rehab • RT in acute care setting also covered under PPS based on statistical cost for each DPG • Prospective Payment for Continuum of Care • Next generation of payment – delivered under a larger system or network – Cradle to Grave services • Assuring svcs through a continuum

  9. PPS Application and Recreational Therapy Across the Spectrum of Care • Acute Care Hospital Inpatient – per episode DPG payment • Inpatient Rehb Facilities (IRF) – per episode payment in case-mix groups made on per discharge basis • Partial Hospitalization – RT is one of several “Activity Therapy” svcs – per diem basis • Outpatient – RT not covered for outpt Medicare at this time based on outdated Soc Sec language • SNFs – RT covered under Medicare Part A – per diem PPS – must be medically necessary and appropriate

  10. Strategies for Success • 6 strategies for recognition and coverage • Assure Active Tx – 1.)individualized plan of Tx or diagnosis 2.)reasonable expectation to improve condition 3.)be for diagnostic purposes 4.)supervised periodically 5.)evaluated by a physician • Specific Physician Orders – Key indicator of medical necessity – scope, intensity and duration • Clear distinction between RT and Activities – RT in addition to mandated activity services in LTC – Some RTs provide both but must be distinct regarding the difference • Cost Analysis and Accountability – be knowledgeable about cost and revenue – from annual to 15-min or every minute

  11. Staffing and productivity – personnel costs are primary expense – ratio of staff hours to tx volume – can vary based on organization mission, patient acuity, and complexity • Compliance with Regulatory Mandates – CMS, JC, CARF – Mgr must be aware of applicable state or local health regulations

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