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Physiotherapy bill format for R&D

hey guys how's it going Tony here so in this episode what I'm gonna do is I'm going to take you through two real claims that have been processed through Medicare Advantage plans you're gonna see the actual reimbursement the actual adjustments that are placed on the claim by the insurance company you're gonna see the patient's coinsurance or co-payments copay and you're gonna see what they're paying now one is an anthem BlueCross BlueShield Medicare Advantage plan and the second is a Humana Medicare Advantage plan so let's jump in and take a look this first claim this was date of service August 19th 2019 so we're in the beginning of September this was just a couple weeks ago you can see the primary diagnosis the secondary diagnosis this is exactly what the claim went out as and what I mean by that is so you see the two and from data service you see place of service 11 now here you see a patient payment in the first line item it has the GP modifier the diagnosis pointer 0 charge because it is a payment and it was a $40 payment this is what the patient paid at the time of service we create a separate line item because we're not sure where the insurance company is gonna credit that copay we know that they have a $40 copay but we don't know where they're gonna credit it and so one unit but if you look to the far right you see this little square this box it's unchecked because that information is not going out to the insurance company on the electronic claim now the second line item you see here bs procedure code that stands that's the initials for the physical therapist who performed the procedure the physical therapist is listed in column J as the rendering provider but from a from a how do I say it from a reporting basis the way this particular software works it's just easier for us to credit this therapist with four units by putting it right in the line items with the claim but there's no charge there's no amount applied and the check the box is unchecked because it doesn't go out to the insurance company this is strictly for reporting and internal use only now the next two line items this is the juicy part so you can see here August 19th we provided three units of therapeutic exercise GP modifier diagnosis pointer billed 120 dollars for the three units the amount applied was 80 and we're gonna get into exactly what that 80 is because that's not how much money we collected that includes adjustments reductions everything like that you can see that the check mark was there because it did go to the insurance company and then the second line item was one unit manual therapy $40 billed $40 credit applied not payment collected that's different so let's get into this claim you can see down here actually real quick where it says primary insurance payment thirty-eight dollars and 31 cents so big picture the patient was responsible for $40 they had to pay out of pocket that was the copay for this visit the insurance company reimbursed thirty-eight dollars and thirty one cents on top of the 40 the patient paid so now we're looking at seventy eight dollars and thirty one cents for a four unit visit a basically active treatment therapeutic exercise a manual therapy so now if we jump into each line item you can see that four and nine seven one one o therapeutic exercise 120 was billed nineteen dollars and ninety one cents was paid by the insurance company that's not per unit as nineteen dollars and ninety one cents to cover their portion of the three units the $40 copay needs to get applied to this line item now we haven't balanced this account yet so that's why this claim is still open but the patient paid 40 that's going to be applied here so the total allowed amount would be the $40 copay plus the ninth 91 so let's say 59 91 is what the allowed amount is for three units of exercise if we want to just quickly say let's say $60 so we're looking at $20 a unit for therapeutic exercise the second line item the manual therapy they reimbursed $18.40 contracted just means we reduce our bill rate by 2160 but we actually collected in our bank account 18 dollars and 41 cents for the manual therapy unit so between the 40 that was the patient copay the 19 1990 been changed for what the insurance paid that puts us at 59 we'll say 90 and then the 1840 so 50 969 pretty close to $70 for the the total collected for this data service now there's no other insurance norther payer this is an anthem BlueCross BlueShield Medicare Advantage plan right now off the top of my head I don't know if this was a PPO HMO what it was we're in network with all of their plans so we were pay it as an in-network participating provider but those of you wondering what is the Medicare Advantage what are they what are those plans paying this one just paid us I just said it what upwards close to $70 just shy of $70 for four active units of care three exercise one manual I've got one other claim in here this is a Humana Medicare Advantage plan so again you see our primary secondary diagnosis you see our line items you see who gets credited the last line item who which therapist gets credited for the four units but above that again we did three units of therapeutic exercise we did one unit of manual therapy total paid by the insurance company in this case was 87 dollars and 22 cents but now I know this plan the patient has a $10 copay if you look here at the bottom so this is the line item for therapeutic exercise three units we can see the insurance paid 65 97 so we'll round up to sixty six dollars contract adjustment of forty to sixty eight and then another adjustment of 135 so these are the reductions from the billed amount the ten dollar balance is the patient's copay and then on the next line we see the insurance paid twenty one twenty five contract adjustment eighteen thirty two secondary adjustment of forty three cents so reason code two fifty three I'll look it up with you off the top of my head I'm gonna guess it's sequestration but I'm not positive but I'll show you where to find that information so for Humana date of service same CPT codes we're looking at sixty-five sixty-six seventy six with the copay eighty six ninety six ninety seven dollars let me go back here just yeah you know primary insurance paid eighty seven patient as a $10 copay ninety seven dollar reimbursement for this plan compared to the seventy dollar reimbursement on the Anthem Blue Cross plan compared to the fifty dollar max allowed on some of our UnitedHealthcare Medicare Advantage plans and those plans have a forty five dollar copay by the patient and the insurance is paying five dollars so there's some major considerations going on there if you're looking at being an in-network provider for United Healthcare we've seen it through the board's many times definitely better to be out of network for United Healthcare but I don't have a claim to process because we do things differently with UnitedHealthcare Medicare Advantage and we're on the way out of that contract we just don't get them we don't see them we can't afford them but from memory the last one we had the reimbursement was five dollars from the insurance company forty five dollars from the patient so guys I I was gonna show you bonus content we're to look up the reason code let me see if I can get out of here real quick and I know you guys can't see the top of this the address bar but basically what I'm doing is I'm typing in reason code let's find it here 253 yeah so reason code 253 and I always mess up the language if it's reason code or remark code yeah so I don't know if you guys can see this looks like you can Medicare yo B sequestration payment reduction so that is just a reduction there is no way around why it's not listed on the anthem BlueCross plan I don't know what you don't see here is the MPP R reduction which again this is the way the EO B's are coming in I'm showing you from our system exactly what it really looks like so guys if you need more information if you have other questions please post them in the comments I'm posting this to YouTube and then sharing it out to the Medicare billing group but as always if you're looking for strategies to grow your private practice if you're looking for ways to better understand Medicare and some of the other payers and if you're looking for tools that will help you reach the success you want subscribe to the channel ring the notification bowell this way you're the first one to know when we post a new video in the meantime I'll keep working on this I hope this was helpful let me know what you guys want to know what your questions are I'll catch you in the next video thanks so much for watching