The document discusses different levels of care including acute care in a hospital setting, inpatient rehabilitation, skilled nursing facilities, outpatient care, and home health. It also covers reimbursement topics such as Medicare, Medicaid, managed care networks, and maximizing reimbursement through detailed progress notes. The overall purpose is to outline healthcare services and levels of care as well as payment and documentation best practices.

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 POST
ACUTE 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 AND
MEDICAID 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.