The Billing Headache
Do you struggle with trying to understand how the system works? So do I actually, but what I'm really referring to here is the world of billing for therapy. What's the difference in how patients are billed? This can be a confusing area for many when it comes to the current therapy reimbursement guidelines.
In the Long Term Care arena, most of the revenue is generated from Medicare. Depending on the status of the patient will determine which Medicare fund will pay, and how much. A skilled patient will be reimbursed under Medicare Part A benefits. The skilled patient is the person who entered the nursing home after a qualifying hospital stay and receives therapy. This type of patient could be the person recovering from an accident or illness seeking to rehabilitate and return home. This can also include residents from the nursing home that have been hospitalized for the qualifying number of days, and will probably remain in LTC.
Revenue in LTC is also generated from Medicare under the Part B guidelines. Patients in this category are current SNF residents who require therapy for some reason, and have not had a qualifying hospital stay. These patients will most likely remain in LTC.
The method to figure reimbursement for both Medicare funds is different. Medicare A depends on the number of therapy minutes delivered within a specific number of days. The higher the number of therapy minutes, the higher the reimbursement rate. This is paid as a daily all-inclusive room rate, meaning the SNF receives a set daily amount for all care and needs of the patient. The therapy contractor will receive a portion of this revenue based on their negotiated contract with the SNF.
Therapy under Medicare Part B is paid based solely on the treatment delivered. Each specific type of treatment has been assigned a code, and is paid on a unit (15 minutes) or a flat rate per code. Again, the SNF and therapy contractor negotiate a split of this revenue.
In some states there are still additional funds available for therapy from Medicaid. Medicaid is a state funded program similar to Medicare. However, Medicaid reimbursement is usually a miniscule figure that does not cover the actual costs incurred, but again this can vary from state to state. Many times Medicaid also limits the type of treatments that are reimbursable, or what type of facility is allowed to bill for services.
Private insurance normally only covers therapy costs in an out-patient setting. Exceptions to this are insurances specifically set up for nursing home care or senior citizen plans. Therapy for private insurance is reimbursed on a per unit/code rate similar to Medicare Part B. The actual dollar amount for each unit/code will again vary according to the treatment.
Private pay for therapy is the remaining option. Maybe some millionaires pay for therapy out of pocket, but at current rates you could go broke quick. The few people that I've encountered that pay privately usually only come for a few treatments anyway. Of course there are the few who exhaust their therapy benefits and pay privately to continue.
And just to keep things interesting, new rules are made constantly. Just as you're sure you understand it all, changes will happen and it's like a whole new system. But then, you like learning new things, right?
Until next time, hope all your thoughts are good,
Tim