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Reimbursement
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  • 1. HOW DO WE MAKE SURE OUR SERVICES ARE PAID FOR???
  • 2. LEVELS OF CARE: ACUTE CARE HOSPITAL SETTING; INCLUDES SPECIALIZED UINTS SUCH AS ICU, PACU, NICU, CCU, SICU, AND BURN UNITS… THE PATIENT IS SICK OR INJURED AND NEEDS MEDICAL MANAGEMENT.
  • 3. LEVEL OF CARE: IN-PATIENT POSTACUTE CARE (REHAB) ALSO REFERED TO AS IN-PATIENT REHAB. PATIENTS ARE MEDICALLY STABLE PATIENTS NEED TO IMPROVE FUNCTION BEFORE THEY CAN SAFELY RETURN HOME. PATIENT MUST MEET 3 HOUR RULE
  • 4. LEVEL OF CARE:SKILLED NURSING FACILITY (SNF) PATIENTS REQUIRED SKILLED SERVICES INCLUDING NURSING (IV ANTIBIOTICS), PT, OT, & ST. COMPLICATED SYSTEM BASED ON AMOUNT OF TIME SKILLED TREATMENT IS REQUIRED COVERS 100 DAYS OF CARE: 1ST 20 AT 100% AND REMAINING 80 DAYS USUALLY 80% COVERAGE OF COST. GIVES THE MORE DIBILITATED PATIENT TIME TO REHAB
  • 5. LEVEL OF CARE:OUT PATIENT CARE PATIENTS HAVE THE ABILITY TO COME TO CLINIC TO RECEIVE PT CARE. PATIENTS USUALLY MUST PAY FOR CO-PAYS OUT OF POCKET IF NO SECONDARY INSURANCE IS AVAILABLE. CO- PAYS ARE ESTABLISHED BASED ON THE PAY RATES OF INDIVIDUAL POLICIES. SOME PT CLINICS ARE MOVING TO A FEE FOR SERVICE MODEL WITH INDIVIDUAL INTERVENTIONS PRICED AND THE PATIENT PAYS OUT OF POCKET. THIS OPTION ALLOWS INTERVENTIONS TO BE REASONABALLY PRICED AND NO BACK AND FORTH WITH INSURANCE COMPANIES.
  • 6. LEVEL OF SERVICE: HOME HEALTH RESTRICTIONS ON PATIENTS:PATIENT MUST BE “HOME BOUND” WITH A FEW EXCEPTIONS BENEFITS : PATIENTS CAN STILL RECEIVE SERVICES EVEN IF THEY DO NOT HAVE TRANSPORTATION. NOT COVERED BY SOME INSURANCES PROGRESS CAN BE LIMITED DUE TO LACK OF FACILITIES AND OR EQUIPMENT
  • 7. REIMBURSEMENT PATIENT IS CONSIDERED THE 1ST PARTY PROVIDER IS CONSIDERED THE 2ND PARTY INSURANCE COMPANY IS CONSIDERED THE 3RD PARTY
  • 8. CMS-CENTERS FOR MEDICARE ANDMEDICAID SERVICES MEDICARE-PART A & PART B MEDICAID SOCIAL INSURANCES
  • 9. MANAGED CARE PATIENTS ARE ENROLLED IN HEALTHCARE NETWORKS PCP-PERFERRED CARE PROVIDER- DOCTOR THAT MANAGES THE PATIENTS CARE. PATIENT MUST GO THROUGH PCP FOR ANY CARE PPO- PREFERRED PROVIDER ORGANIZATION- CONTRACTS WITH INSURANCE COMPANIES TO PAY FOR SERVICES ON A SET FEE SCHEDULE. HMO-MEDICAL PRACTICE PLAN THAT ACTS AS BOTH THE INSURER AND PROVIDER.
  • 10. REIMBURSEMENT FOR MOST INSURANCE COVERAGE- IF A SERVICE OR PIECE OF EQUIPMENT IS NOT COVERED BY MEDICARE; OTHER CARRIERS ALSO DO NOT PROVIDE COVERAGE.
  • 11. Maximizing Reimbursement Progress notes must: 1. Reflect a comparison between initial status and current status. 2. Include impairments , and functional limitations, and degree of disability in clear ,concise, objective, measurable terms. 3.Distinguish between verbal and physical cues 4. Include regular patient updates.
  • 12. CONTINUE 5. Provide updates that are consistent with the initial evaluation. 6. Indicate why progress might be slow. 7. Provide evidence of skilled treatment and why it is necessary. 8. Include time spent in delivering the service. 9. Ongoing need for skilled interventions 10. How interventions bring about functional improvements.