Coverages
RehabAlpha is still under active development. It is not yet HIPAA compliant and should only be used with dummy data.
A coverage is a relationship between a patient, a payor and a time period. You can think of a coverage like an insurance policy; it defines
- who pays for care,
- for how long, and
- under what conditions.
Coverages are critical for determining how therapy services are billed and reimbursed. They often include authorizations, copays, deductibles, and other financial rules.
Data model
RehabAlpha stores coverages under a patient:
A single coverage is linked to exactly one payor and zero or more authorizations.
Coverages are also referenced by billing periods within an admission. This is how RehabAlpha know which payors to bill for therapy services.
Discussion
When a patient recieves therapy, its important to understand which payor is responsible for footing the bill. However, knowing the payor alone is not always enough. Often times, one must know which policy period a charge should be allocated to, as the specific policy period's deductible, copay, coinsurance, etc. must be taken into consideration. RehabAlpha supports this level of detail via coverages.
As mentioned earlier, a coverage is a specific relationship between a patient, a payor, and a time period. For example,
- Patient Bob Anderson has a coverage from Aetna for the period 1/1/2020 thru 1/1/2021 with a $2000 deductible
- Patient Bob Anderson also has a coverage from Medicare Part A for the period 8/13/2012 thru ongoing
- Patient Patty Labelle has a coverage from Medicaid for the period 3/20/2020 thru ongoing
Before creating a new coverage for a patient, you should ask Does the payor already exist in my organization's list of payors? If the answer is no, you should first add the payor. Then you can add the patient's coverage via the new coverage form, first selecting the payor and then inputting the coverage start date. If you don't choose an end date, it's assumed that the coverage runs indefinitely.
Medicare coverage
Most (but not all) patients receive coverage for Medicare part A and B the day they turn 65. This coverage continues indefinitely.
Private payor coverage
A patient's therapy services may be covered by a private payor such as their child, spouse, and even the patient themself. To set this up,
- first add the private payor
- then create a new coverage for the patient and select the private payor you just added
Since it's very common for a patient to pay for part of their therapy bill, each new patient is also added as a payor, and the patient recieves coverage from that payor from "way back (i.e. Jan 1, 0001)" thru an indefinite end date.