Billing overview
RehabAlpha is still under active development. It is not yet HIPAA compliant and should only be used with dummy data.
In therapy operations, billing can mean two different reimbursement workflows. RehabAlpha supports revenue-cycle setup and reimbursement calculations for both contexts, but it does not currently submit claims to payors or manage direct billing.
Two meanings of billing
Facility reimbursement to a therapy company
In a contract therapy arrangement, a therapy company furnishes services for a facility. The facility reimburses the therapy company according to their contract. RehabAlpha can calculate the facility's financial obligation and create facility invoices for this workflow.
This workflow applies only to contract therapy. If you operate a small outpatient clinic or an in-house therapy department, you will generally not use facility contracts or facility invoices.
Payor reimbursement to the billing provider
In the other workflow, a payor reimburses the billing provider—typically the facility—for covered therapy services. RehabAlpha uses the payor and billing provider saved on each billing episode, together with payor arrangements, to determine the applicable payment model and calculate reimbursement information. Facility billing-provider rules only supply defaults when an episode's payor or facility is selected.
This is the reimbursement relationship most outpatient clinics recognize. It is separate from any contract between a facility and a therapy company.
Service-day billing details
Billing details brings together the service items for one facility, patient, payor, billing provider, and service date. It exists because reimbursement rules can apply across all of a patient's services in that five-key partition, rather than to each clinical document separately.
For example, if a patient has two treatment documents on the same day, each with a 97110 service item, billing details retains both source items and can aggregate them when it calculates units and reimbursement.
The diagrams below show how admissions and billing episodes lead to service-day billing details.
Facility, patient, and admissions
Each patient record belongs to one facility. An admission records a period of care for that facility patient, and the patient can have multiple admissions at the same facility.
Billing episodes and therapy cases within an admission
Within an admission, billing episodes describe the billing arrangements for therapy services, and therapy cases organize the clinical documents:
- A billing episode identifies the primary payor, billing provider, date range, and disciplines or specific therapy cases whose services apply.
- A therapy case holds the clinical documents for one discipline, such as PT, OT, or SLP.
In a typical scenario, one admission has one billing episode and one therapy case per discipline receiving care. The billing episode can apply to PT, OT, and SLP together, while each discipline keeps its own clinical documents in its therapy case.
For example, Jo receives PT, OT, and SLP during an admission at Hilltop. One Medicare Part B billing episode applies to all three disciplines from January 1 through January 31:
The billing episode and therapy cases belong to the same admission. Services from all three cases match this episode when their service dates fall within its date range.
Billing episode
For Jo's example, set up one billing episode, choose Pick by discipline, and select PT, OT, and SLP. You do not need a separate billing episode for each discipline when the same payor and billing provider apply over the same period.
PDPM billing episodes always use Pick by discipline and include PT, OT, and SLP. They cannot target specific therapy cases.
Therapy case
Each therapy case can start and end on different dates while its services still match the same billing episode. In Jo's example, all three cases fall within the January billing episode:
Clinical and service documents
RehabAlpha supports five kinds of clinical documents, three of which are considered service documents:
| Clinical document | Is also a service document? |
|---|---|
| Evaluation | ✅ Yes |
| Treatment | ✅ Yes |
| Progress report | ❌ No |
| Re-evaluation | ✅ Yes |
| Discharge | ❌ No |
A service document is a clinical document that includes a service log.
Service logs and service items
A service log is a record of CPT-coded services provided during the evaluation / treatment / re-evaluation. Each entry in the Service log is a service item. It records the CPT code and relevant service details, such as minutes and notes.
For example, a treatment can include these service items:
| CPT code | Service | Minutes | Notes |
|---|---|---|---|
| 97110 | Therapeutic exercises | 20 | Strengthening program |
| 97530 | Therapeutic activities | 15 | Transfer practice |
Many (but not all) payors use these service items to calculate reimbursement.
When an admission needs more than one billing episode
An admission can have multiple billing episodes when its billing arrangements change or differ between therapy services:
- A payor changes over time: End the first episode when its responsibility ends and start another for the new payor. For the same services, keep the episode periods from overlapping.
- Different services have different payors at the same time: Use separate episodes for the relevant disciplines or specific therapy cases. For example, one episode could apply to PT and OT while another applies to SLP.
For payment models other than PDPM, each billing episode offers two ways to select its services:
| Selection | Matching services |
|---|---|
| Pick by discipline | Service lines in the selected disciplines whose service dates are within the episode's date range |
| Pick specific therapy cases | Service lines in the selected existing cases whose service dates are within the episode's date range |
Specific-case selection also lets you assign concurrent cases in the same discipline to different payors. For example, two PT cases can run at the same time while one case is covered by Medicare Part B and the other is private pay. Each service line can match no more than one billing episode, so RehabAlpha rejects selections and dates that could create two matches.
Service-day billing details
Each facility, patient, payor, billing-provider, and service-date combination has its own service-day billing details. For example, services for two payors on the same date remain in separate groups. Services assigned to two different providers—or to a provider and no provider—also remain separate:
Before creating these groups, RehabAlpha matches each service line to the billing episode whose date range and discipline or specific-case selection both apply. A service line can have zero or one match, but never two.
Owners, Admins, and users with the Facility manager, Biller, or Auditor profile can open Billing details from the Services or interventions provided today section of a service document at that facility. In the dialog, review:
- Summary: The facility, patient, payor, payment model, matching payor arrangement, billing provider, service date, and calculated payor reimbursement.
- Service items: Every source service item included in the service-day calculation.
- Payor reimbursement: The calculated service-item units and reimbursement details. Claim modifiers are applied and displayed at this service-day unit level.
Revenue cycle management in RehabAlpha
RehabAlpha supports these major revenue cycle management (RCM) components:
- 🏢 Billing-provider and payor setup: Record the billing identity and the payors your organization works with. See Set up a billing provider and Set up a payor.
- 🪪 Patient coverage and authorizations: Track patient-specific coverage periods, benefits, and authorization details. See Set up a patient coverage.
- 🗓️ Billing episodes: Identify the primary payor, dates, and disciplines or specific therapy cases that apply to an admission. See Set up a billing episode.
- 💵 Payor arrangements and payment models: Configure how a payor reimburses a billing provider, including fee schedules and supported payment models. See Set up a fee schedule and Payment models overview.
- 🤝 Facility contracts and invoices: For contract therapy, calculate what a facility owes the therapy company and create an invoice. See Set up a facility contract and Set up a facility invoice.
RehabAlpha does not currently prepare, submit, or manage claims and remittances between the billing provider and payor. Use RehabAlpha's billing setup and reimbursement information to support your revenue-cycle workflow, then complete claim submission and payor-payment processing in your current billing system.
What to do next
Start with Set up a billing provider and Set up a payor. Then add patient coverage and billing episodes for the admissions you manage in RehabAlpha.