Reimbursement Sources Reimbursement Sources

Reimbursement:
What Every Music ! Medicare ! Medicare

Therapist Should Know –Partial Hospitalization (PHP) –Prospective Payment System

 (PPS)
! Healthcare Common Procedure ! In-Patient Rehab & Psychiatry
Jodie Deignan, MA, MSN, ARNP,
LMHC, MT-BC  Coding System (HCPCS) ! Hospice

Brewster, MA ! Activity Therapy Code: G0176 ! Skilled Nursing Facilities (SNFs)

April 1, 2011

Reimbursement Sources Reimbursement Sources Reimbursement Sources

! Medicare ! Medicaid ! Private Insurance

–Indemnity
–Minimum Data Set (MDS) –Approved Providers –Preferred Provider Organization
! Restorative Care (PPO)
–Waiver Programs
! Section
O: Special Treatments,
–Health Maintenance
Organization (HMO)
  Programs, And Procedures
O0400: Therapies –Point of Service (POS)

Reimbursement
Reimbursement Sources Reimbursement Sources
Terminology
! Diagnostic Codes
! Workers’ Compensation ! Adoption Subsidy
! State and County Boards/ –ICD 9 (CM)
! Procedural Coding
! TRICARE Departments
– Health –CPT! 2011
– Social Services –HCPCS
! Automobile Insurance
– Developmental Disabilities ! Revenue Codes
Reimbursement Process Reimbursement Process Reimbursement Process

! Step One: Obtain your National
 Provider Identifier Number
 (NPI)
– “Respiratory, Developmental, Rehabilitative
  and Restorative Service
Providers”
! https://nppes.cms.hhs.gov/NPPES/Welcome.do
! Step Two: Seek Referrals
  Physicians, Psychologists, Social
 Workers, Case Managers, Parents, Clients,
Allied Healthcare Providers
! Step Three: Collect Insurance
     Information
– Music Therapy Pre-Approval Form
– Assignment of Benefits Form
– HIPAA Notice
! Step Four: Determine Client Needs
– Initial Assessment: Brief or Full
– Define the scope, duration, and
 frequency of music therapy
 treatment
– Determine Medical/Behavioral
 Necessity

Reimbursement Process Reimbursement Process Reimbursement Process

! Step Five: Prepare Marketing ! Step Six: Contact Primary Care ! StepSeven: Select Procedure
     Materials Physician
     Codes that best describe
– Provide MT information
– Music Therapy Definition   MT interventions
– Seek Written Referral 
– Supportive Research
– Request Diagnostic Codes – Current Procedural Terminology (CPT)
– Health Care Industry Recognition
! International Classification of Diseases-
– Determine Rates/Fees Per Code
– Qualifications  9th Revision (ICD-9)

Reimbursement Process Reimbursement Process Reimbursement Process

! Step Eight: Call the Insurance ! Step Nine: Provide MT Interventions ! Step Ten: Complete Claim Forms
     Company – Document all elements of treatment
– Request Case Manager Review – CMS 1500
! Assessment  
– Present Diagnostic (ICD-9) and – http://www.cms.hhs.gov/manuals/downloads/
! Treatment Descriptions
 Procedure Codes (CPT) clm104c26.pdf
! Potential Cost Savings
– Review Pre-Approval Process ! Step Eleven: Submit Claim
! Client Response to Treatment
– Negotiate Rates
– Request Reporting Requirements ! Functional Outcomes Achieved – Include Required Attachments
Reimbursement Process Reimbursement Tips Resources

! Step Twelve: Follow-up with Payer – Don’t Stop at “NO” ! www.musictherapy.org

– Appealing an Adverse Decision
– Develop Relationships with Insurance ! www.cbmt.org
! What was the reason for denial?
! Who made the initial decision?  Company Case Managers ! www.cms.hhs.gov
! What is the appeals process?
– Present Clear and Accurate Information ! www.ingenixonline.com
! What additional information is needed to
 review the appealed case? – Respond to All Communication in a ! www.amapress.com
! Involve the referring physician
  Timely and Professional
! Involve the patient/family