Show Me the Money- Delivering
Ethical and Reimbursable Services
within Healthcare Payer Sources
Amber Heape, MCD, CCC-SLP, CDP
Clinical Specialist- PruittHealth
Amber Heape- Disclosures
Relevant Financial Relationships:
• Salaried Clinical Specialist for PruittHealth
• Receives honoraria for CE courses and
seminars taught, including this one
Relevant Non-Financial Relationships:
• Former SCSHA Board Member
Course Objectives
• The learner will classify major payer sources
and requirements for skilled rehabilitation
services within each source.
• The learner will compare and contrast
documentation requirements for each payer
source.
• The learner will apply ethical principles to
reimbursement scenarios in order to
synthesize information gained in this session.
Most Common Payor Types
• Medicare
• Medicaid
• Private Insurance
Medicare• Health insurance program that covers those
eligible: age 65 or older, some disabled
under 65, people of all ages with ESRD
(dialysis or transplant).
Medicare Part A
• (Hospital Insurance/ Rehab)
• Pays for care in hospital, SNF (rehab), hospice,
and some home health
• Payment based on ProspectivePayment System
(RUGS levels)
• Most people get when they turn 65, as long as
they or spouse worked and paid Medicare taxes
• Medicare Supplement Policies: (HMOA)
Individual policies vary, some are RUGs
payment based, some are set fee per day.
Medicare Part B
• (Medical Insurance- usually in addition to
part A)
• Doctor’s services, outpatient hospital care,
outpatient or inpatient therapy, some home
health care
• Pay a monthly premium, just like insurance,
and often have a copayment for services
Medicare Part D
• (Pharmacy/ prescription drug plan)
• Pay a monthly premium
Medicaid
• Joint federal and state program that pays
medical costs for people with limited income
and resources
• Usually helps pay costs (co pays) not covered
by Medicare
• Also offers some assistance with personal care
and transportation to dr. appts.
• Payors include Community Medicaid (patients
live at home) and Long-Term Care Medicaid
(patients live in SNF)
Rules for Medicare Part A Rehab
•
In order to qualify for an inpatient rehab stay paid by Medicare:
– Must be Medicare qualified
– Be admitted (not observation) in hospital for 3 midnights
– Pays 100% of first 20 days of inpatient rehab
– Typically pays 80% of next 80 days of rehab. Balance paid by insurance or
privately
– Continued rehab dependent on continued progress during those 100 days
– If you are d/c from the hospital, you have 30 days to begin an inpatient
program
•
Once in inpatient rehab, Medicare part A pays a “per diem” rate based on the
RUG (Rehab Utilization Group) level of the patient
Medicare RUGs System
• In 2010, the case mix classification system
(RUG IV system) was revised. Payment is
based on the number of therapy minutes, as
well as the medical complexity of patient,
including levels for ADL status.
Medicare RUGs System
• Rehab Ultra High:
– 720 minutes (5 days one discipline/ 3 days another)
• Rehab Very High:
– 500 minutes (5 days/ 1 discipline)
• Rehab High:
– 325 minutes (5 days/ 1 discipline)
• Rehab Medium:
– 150 minutes (5 distinct days of therapy in a combination of
disciplines)
• Rehab Low:
– 45 minutes (3 days, any combination)
RUGS determined by looking back 7 days from the ARD or Change of Therapy review.
The ARD is determined by rehab director/ department head
Why am I assigned a specific number
of minutes with each patient?
Medicare Part B- Therapy
• Part B pays per unit or service billed (by
therapy type) There is no set amount of
time per patient.
• Typical Speech Therapy CPT Codes are
billed per service
– 92607- (Treatment of Speech/Language)
– 92526- (Treatment of Dysphagia)
Treatment Delivery
• Co-Treatment- Treatment between 2 disciplines no longer has to be
split in time between the two. You must document the reason for cotreatment and goals your discipline focused on.
• Individual vs. Group treatment
– Medicare pays group up to 25% of total billed minutes per discipline on
part A’s.
– Medicare Part B reimbursement rate for group therapy is very low, so often
discouraged
• Concurrent treatment- “Dovetailing”- treating up to 4 patients
simultaneously, with all working on different goals.
Supportive Diagnosis Coding
• Typically use the acute medical diagnosis
for hospitalization as the therapy POC
medical diagnosis.
• Also code using the diagnosis that most
affects the patient’s need for Speech
Therapy
• Should tie the diagnosis in narrative of
reason for referral
Documentation
• Physician Orders
• Required by EVERY payor type for evaluation and/or
treatment of the patient
• Physician “Cert”
– Medicare Part A therapy services included and
signed every 30 days
– Medicare Part B POC must be signed by MD
Ethics and Clinical Judgment
Thank You!