Athletic Training Management

1. Athletic Training Management Chapter 11 Third Party ReimbursementEdited by Jeff Konin, Ph.D., ATC, MPT

2. AT and 3rd 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 Medicare’s lead • Claims my be rejected for any number of reasons (see table 11.1)

3. Importance of Billing • 3rd 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

4. 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 3rd 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

5. 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

6. 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

7. 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

8. Reimbursement Codes • The treatment intervention must always match the intervention code in order for a 3rd party to pay • For 3rd party payers the CPT or UB codes are matched to the ICD codes to ensure appropriate interventions

9. 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

10. 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.

11. 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

12. 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

13. 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

14. 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.

15. Reimbursement Codes • Universal Billing (UB) code are similar to CPT codes and used in hospitals

16. Preparing Documentation • Documents should be developed providing accurate comprehensive information about a patient’s condition and treatment intervention and that conforms to the requirements of 3rd party payers • Minimum needs include patient registration form, a patient encounter form (fig 11-1), a daily journal, an individual patient’s accounts form, a treatment note, and insurance claims forms (fig 11-2 HCFA- 1500 and UB-92)

17. 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 patient’s 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

18. 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

19. 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

20. Handling Denied Claims • Go back and review the patient’s policy to reestablish patient’s 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

21. 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 • Recipient’s 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

22. Handling Denied Claims • Claim number • Reiteration of the reason for denial • Explanation of why charges should be paid

23. 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

24. 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

25. 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 3rd party payer, within both federal and state law and scope of practice, reimbursement should be possible

26. 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