Athletic Training
Management
Chapter 11
Third Party Reimbursement
Edited by Jeff Konin, Ph.D.,
ATC, MPT
© 2006 McGraw-Hill Higher Education. All rights reserved.
rd
3
AT and
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)
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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.
© 2006 McGraw-Hill Higher Education. All rights reserved.
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 percase basis
– Originally designed for acute hospital care
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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.
© 2006 McGraw-Hill Higher Education. All rights reserved.
Reimbursement Codes
Universal Billing (UB) code are similar to
CPT codes and used in hospitals
© 2006 McGraw-Hill Higher Education. All rights reserved.
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)
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
Handling Denied Claims
Claim number
Reiteration of the reason for denial
Explanation of why charges should be paid
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.
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
© 2006 McGraw-Hill Higher Education. All rights reserved.