Reimbursement Issues (Full Version)

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SJBird55 -> Reimbursement Issues (March 20, 2005 8:36:00 AM)

There are a lot of educated folks that post here... I've been wondering and contemplating the future.

What would be a reasonable process or system for reimbursement? The fee for service doesn't work - it can lead to both overutilization and also creates a reward type atmosphere for providers to provide as many services in a visit as possible for increased monetary gain. I don't know, but in a way, I think the current system may even reduce the capability for providers to capture evidence-based medicine in their practices. And the current system is based on ICD-9 codes which come on we all play around with so we get paid. (For example "strains" are not reimbursed, but leg pain or shoulder pain would be.) So... technically all the data any insurance company has is crap because a true description of what we think we are treating is never indicated.

Would a better system consider the outcomes that are achieved? That would be mentally difficult because we have no standardized format for reporting our services provided or measuring outcomes.

Would a better system be a flat fee for a particular diagnostic category that also considers comorbidities of the patient? That would allow complete freedom for providers and at the same time change thought processes to be more efficient because the sooner the patient is discharged the more money would be made by the provider. Again, something would need to be in place to ensure patients aren't discharged prior to optimal outcomes being achieved.

Would a plan old flat hourly rate of service provided be an option? Lawyers do it... moving companies do it... mechanics do it... could we do it?

With the potential of a greater population without insurance coverage, how can something be in place that will easily allow for that particular population to afford needed services?

Has anyone else been dreaming of how things could be different? Or had any "what-if" thoughts?



hmgross -> Re: Reimbursement Issues (March 21, 2005 6:31:00 AM)

I agree with you on the fee for service. I don't know if a flat hourly rate would be any better. Maybe paid per "condition" but how? The way we eval/treat is not as straightforward as something like "impacted ear wax" where you see what is wrong, do something about it (flush it out, which by the way costs $120) and document success (no more wax in the ear!) How would we be able to do that when there appears to be an unlimited amount of approaches for back pain. Sorry that I don't have the answer. Maybe somebody out there does.



JLS_PT_OCS -> Re: Reimbursement Issues (March 21, 2005 7:19:00 AM)

Hourly rates are an interesting approach.
Unfortunately, even patients with the same problem (assuming we all even know for sure it is the same) take different approaches and different timelines to feel better.

I agree with Holly that eval/tx often isn't as simple as removing earwax, but until we attempt to codify and standardize it to some degree, we will be lost in the morass of variability in approaches.

I think the standardization of care has a lot to do with the eventual determination of a fair billing system, but until we are more consistent in all of our evals/treatments, we can expect more of the same.

Ultimately, when patients are in control of their money, they will always make the best cost vs value decision. Any third party payer type system will always muck it up, and usually cost more of the patient's money in "administration" fees. What a joke that is.
Private health care accounts probably come the closest to ideal, in my opinion.



SJBird55 -> Re: Reimbursement Issues (March 21, 2005 8:07:00 AM)

I believe we all agree that the fee for service current system sucks.

The variability in approaches could potentially be altered with a potential system of payment for a particular condition... but as I had alluded to just the "condition" couldn't be the single factor, but also age and comorbidities for example. I'd assume there would still be variability in approaches, but the approaches that are the most efficient would be "the approach" for the business savy. In that particular scenario... I think I could visualize payment for an evaluation and the provider potentially evaluating the level of service that would need to be provided for the condition. Or if therapy isn't appropriate, you get paid for the eval and the patient gets moved along through the system.

I kind of like the hourly rate myself (or the 15 minute rate or the 30 minute rate). Figure out the cost to provide business... figure out how much you want to profit.... and compete with other providers. I'd think keeping the current CPT codes with maybe some altering in the definitions would be a good thing at least from a description of the service provided. If that were the system for payment, I even vision a change in marketing strategies.

It just seems to me that there could potentially be a better system in place where it is win-win for everyone involved. I don't like the way it is now... the control is too far on the side of the insurance companies. (And where I practice that's the way it is...)



apolipo -> Re: Reimbursement Issues (March 21, 2005 10:01:00 AM)

I also work in MI and know just how much third party payers (TPP) determine what I do with my time. I figure at least 50% of my paperwork is a direct result of insurance requirements.

I'm curious about the idea of private medical accounts. I can see the positives, but the first negative I think of is "I don't have enough money in my account to pay for this".

The next thing I think of is those who can provide immediate results in a minimum of visits will succeed, i.e. Chiros and shady PTs willing to operate like a chiro (pop'em and send them home). My wife's family lives in a rural area where no insurance is common. The Chiros are popular because their single visit fees are not outrageous and people get "results", at least for a few days/hours.

I could see a combo of private accounts for most problems and insurance for emergencies/surgeries/major expenses being a possibility.

I would love to see some change.

mike t



Nicole Matoushek PT MPH CSHE CEES -> Re: Reimbursement Issues (March 21, 2005 6:29:00 PM)

For several years, I was the clinical advisor director for a utilization review company that provided oversight for both the fee for service and the per-diagnosis reimbursement environments. What was stated above: the incentive is to overutilize in the fee for service and under utilize in the diagnosis-rated program, was true. In addition, those providers who were most business savvy and took an active approach to patient treatment were the most successful in the diagnosis-rated program. I am familiar with the co-morbidities, multiple diagnoses and clinical outliers and how they can best be treated/managed in these programs.

So, in order to provide the most efficient and effective care and to ensure neither over utilization, nor under utilization of care occurs, clinical reviews or flags can be put in place. Policies and procedures based on clinical practice guidelines, medical necessity and clinical indicators can be and have been developed. I have an entire training program for therapists, available as web-based training, if anyone is interested, one topic is "Clinical Management in Skilled Therapy" another is "Optimizing Outcomes in Diagnosis-rated and Fee for Service Programs. If you are interested in the training programs and concepts, email me personally at contact@workinjuryconsultants.com or visit [URL=http://www.workinjuryconsultants.com.]www.workinjuryconsultants.com.[/URL]

I happen to be a big supporter of the diagnosis-rated program concept.It can be a tremendous opportunity for the therapy professional to raise the bar on practice outcomes.

Truly,
Nicole



Sebastian Asselbergs -> Re: Reimbursement Issues (March 22, 2005 1:35:00 AM)

In private practice, hourly rates, or parts thereof. In combination with the expected professional and responsible decision making of the practitioner, this represents the most reasonable and fair remuneration of that professional. How this pans out in the various and different communities of the participants here, is a whole other issue. I remember the remuneration in the Netherlands was quite complex in the private practcies - with a variety of insurance combinations and procedural billings. Even in Canada here, the different provinces have different models of funding. Ultimately, it seems that working outside the insurance frameworks (either social or private) is the "cleanest" way to get what one deserves. This however, may well make access to PT very difficult for those with little $$.....



SJBird55 -> Re: Reimbursement Issues (March 22, 2005 2:26:00 AM)

Any thoughts on the new endeavor by Medicare - the trial of payment for performance?



Nicole Matoushek PT MPH CSHE CEES -> Re: Reimbursement Issues (March 22, 2005 5:37:00 AM)

Can some one describe payment for performance for me?

Nicole



hmgross -> Re: Reimbursement Issues (March 22, 2005 6:16:00 AM)

SJ, I am getting reimbursed using ICD-9 840's codes--(sprains/strains) I am doing something wrong/right? I would also like to know more about the payment for performance. Did that have anything to do with a recent story about a surgeon wanting to do a mastectomy vs lumpectomy because reimbursment for mastectomy was better? They said something about revamping the system to allow better reimbursement for the more complicated proceures. I am not a surgeon of course but I think I understood the lumpectomy to be a "quicker" procedure, but is more complicated. Maybe I heard wrong, but if this is what is happening, then the system SHOULD change.



SJBird55 -> Re: Reimbursement Issues (March 22, 2005 7:51:00 AM)

Nicole... go to [URL=http://www.cms.gov]www.cms.gov[/URL] and skim down the column of writing.... you'll see something regarding payment for performance - click on it

I don't know, Holly. At our local hospital system, those codes were not allowed because of a history of a high denial rate. This was through BCBS of MI though.



Nicole Matoushek PT MPH CSHE CEES -> Re: Reimbursement Issues (March 22, 2005 9:50:00 AM)

Thank you SJBird55!



Nicole Matoushek PT MPH CSHE CEES -> Re: Reimbursement Issues (April 3, 2005 10:37:00 AM)

I am still learning about the "payment for performance" reimbursement programs. Does anyone have any personal experience that they can share with therapy reimbursement?

Has anyone in work comp used this sort of program or reimbursement structure.

It sounds rather interesting.

Thank you
Nicole
[URL=http://www.ergorehabinc.com]www.ergorehabinc.com[/URL]



SJBird55 -> Re: Reimbursement Issues (April 3, 2005 11:35:00 AM)

I don't believe that method of reimbursement exists in the physical therapy market.



gomez2 -> Re: Reimbursement Issues (June 29, 2005 6:50:00 PM)

I am starting PT services in an established athletic training facility. Our thought is that a client that comes in for an eval with "issues" that may require PT will get an eval from me at the same flat rate as an athletic performance/training eval. If needed then the client will cont. with me at PT Tx rates that will be a flat rate per 15 min. Clients will pay for services up front and we provide reimbursement documentation.

Any thoughts?



FLAOrthoPT -> Re: Reimbursement Issues (June 29, 2005 8:27:00 PM)

in the next 12-18 months you will see payment based on performance, or really results for that matter. I know in the home health field that oasis scores and pre-determining how muchfunctional gain a patient actually has of attaining compared to how they are now is what payment will be based on more so than just a diagnosis code...things are a changing..



SJBird55 -> Re: Reimbursement Issues (June 30, 2005 1:54:00 AM)

I'm sure we're going to see that change, but what will it be based on in our field?

With the physicians, they are targeting diabetes as one area that has certain processes that need to be met. So... when I've read some of the pay for performance stuff, the targets are more with chronic conditions and getting control of those conditions so there's money paid up front before the patients get into major issues and really into a hole, so to speak.

So, with Medicare, what would be the target for us? How will it be measured? And, I'd kind of think that what we do should have long-term effects, so how long of a term and how would payment be based on that? I can see reduction of falls as a target... I can see targeting folks BEFORE they have osteoporosis as a target... We can have an awesome role preventatively.... but, after patients start going down that decline path and a lot of times by the time that they come to us, we can only get the person to a particular level of function. Also, a lot of what we do does require patient adherence to a certain degree, so in some cases, is it the provider's fault that maybe the expected changes didn't occur?

In my opinion, I think that our role is going to have to be shifted into a greater preventative role. The pay for performance is a great idea, but I think to get the potential results that Medicare would probably be interested in targeting and measuring, then our role would have to come into play WAY before the patient even thinks we're needed. We can and will have a much better ability to reduce falls if we had the chance to see the elderly BEFORE they fell. And, in the case of osteoporosis... by the time they come to us with their pain and kyphotic curves, well... it's a bit too late.

Gomez, when it comes to the amount you charge, from a business perspective you need to make sure your costs of doing business are met. If your set up with what you are thinking of doing covers your costs, then it sounds like a sound plan.



FLAOrthoPT -> Re: Reimbursement Issues (June 30, 2005 4:55:00 PM)

it is not necessarilly pay based on outcome as much as functional progress. For example a patient who is partial weightbearing on a surgical hip may progress fro walker to no device and be fully independent, but this is not to say that this is reimbursed more than the bed bound person who is now chairbound. The final outcome is not paid, as much as the relative predicted outcome progress, that is....how much progress can be made, and you will be paid upon this anticipated progression of ADL even if full independence is not in their future..



SJBird55 -> Re: Reimbursement Issues (July 1, 2005 2:12:00 AM)

If payment is based on the functional progress as you stated, then that is a good idea. Years ago one of the Lewis' had a call for ideas to help decrease Medicare payments. I had suggested something like a sliding fee scale based on functional goals set by the therapist being attained. Never heard anything from whicher Lewis it was that asked for ideas.

Seeing what Medicare has rolled out for their demonstration project for physicians, from an outpatient perspective, I don't see pay for performance being based on what you are saying. My bet is that they are going to target areas of big spending and try to create a situation of chronic issues being addressed much sooner than normal to then see an overall reduction of chronicity in the Medicare population, which for us would potentially be reduction in falls and osteoporosis, especially now that they started the provision of preventative services for Medicare beneficiaries.



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