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  • APTA Working for You: Commercial Payer Updates, September 2018

    The commercial payer world is varied and continually evolving. APTA helps its members by staying on top of changes and bringing the physical therapy profession's voice to the table on a wide range of private payer-related issues. Here's a quick rundown of some of the latest news and APTA activities.

    APTA partners with the American Chiropractic Association (ACA) to submit application for a dry needling CPT code
    APTA and ACA staff and member experts are presenting the application for a dry needling CPT code at the American Medical Association CPT Meeting in Boston, September 27-29. APTA will provide an update on the results of the meeting after the meeting information is made public.

    Aetna and Magellan Health launch a new UM program in 4 states
    On September 1, 2018, Aetna rolled out a new utilization management (UM) program using Magellan/NIA as the vendor. The program is active in West Virginia, Pennsylvania, Delaware, and New York. APTA is actively engaged with Aetna and Magellan, along with chapter leadership of the included states, to mitigate impacts on patient access and administrative burden.

    APTA hosts another successful Insurers' Forum
    On September 14, 2018, APTA hosted its annual Insurers' Forum. Thirty-four payer representatives and case managers from around the country attended the meeting, an event that brings together representatives from the payer policy, case management, and health care industry to discuss trends in physical therapy that affect payment.

    Again this year, the forum was well-received as an opportunity "to collaborate with other PTs on the insurance side," as one attendee stated.

    APTA staff to lead a National Quality Forum work group on opioid stewardship
    APTA Senior Payment Specialist Alice Bell, PT, DPT, has been identified as a work group lead for the National Quality Partnership Opioid Stewardship Member Network. This group will expand on the work of the National Quality Partnership Opioid Stewardship Workgroup to promote adoption of effective strategies for opioid stewardship. Bell will moderate the first webinar of this group, titled "Partnering With Patients for Pain Management: the Path to Opioid Stewardship," and to held on October 2. To join the Opioid Stewardship Member Network, email the NQF Member Network.

    Aetna's policy clarifications increase access to PT Care
    Major commercial insurer Aetna recently provided clarification on policies related to payment for physical therapy, and it's good news for physical therapists (PTs) and their patients.

    The clarifications help to answer questions related to the company's physical therapy policy, specifically around payment for evaluations and the ways direct access provisions can affect payment. A recent PT in Motion News story covered the highlights.

    More on the Aetna clarifications: evaluations could be eligible for payments sooner than the 180-day wait period
    Although Aetna's policy reads that "physical therapy evaluations will be eligible for payment once every 180 days," Aetna representatives have informed APTA that evaluations performed within 180 days of the original evaluation may be allowed upon reconsideration or appeal, providing the evaluation is for a new or unrelated condition.

    APTA attends National Business Group on Health's "Workforce Strategy" conference
    As part of APTA's ongoing efforts to engage employers and better understand their challenges, APTA staff attended the "Workforce Strategy: The Future of Work, Life and Health" conference sponsored by the National Business Group on Health, (NGBH). The agenda included topics such as employee engagement, digital health, results of health-related pilot projects and emerging innovations for better health and well-being. The importance of determining centers of excellence using data was stressed. Several presenters mentioned physical therapy for low back pain in lieu of surgery and the need to assess the cost savings of avoiding the surgery. The members of the NBGH represent the human resources and health benefits interests for some the largest companies in the US, most with a global footprint. Its goal is to help employers optimize business performance through creative health improvement and health care management initiatives.

    Tiered coding for PT evaluations: new APTA podcast series answers common questions
    As the payment landscape for 2019 comes into focus, it's becoming clear that physical therapists (PTs) will continue coding evaluations according to a 3-tiered system based on patient complexity.

    In its latest efforts to help underscore the importance of continued accurate coding, APTA produced a series of free podcasts on the CPT evaluation codes. The 5-part series covers a general overview of the coding change and addresses common questions related to determining levels of stability, documenting elements, the relationship of examination time to code selection, and coding in reevaluation. With episodes ranging from 5 to 8 minutes in length, the individual podcasts are convenient for quick listens on the go or during breaks at the clinic.

    APTA offers a range of resources for learning more about commercial payment and staying connected: sign up for the Coding, Billing, and Payment online community to join the conversation and share experiences; stay informed by visiting APTA's commercial insurance webpage to access information and download tools including customizable appeals letters; and subscribe to the Payment edition of APTA's Friday Focus newsletter series to receive a monthly compilation of payment-related news and resources. Questions? Email advocacy@apta.org.

    Comments

    • I am looking forward to enrolling into a pta program at suny new paltz. I am also employed at suny new paltz.

      Posted by Carl Richardson on 9/28/2018 2:49 PM

    • Is anyone recommending to Aetna that P.T. should be direct access and not require a referral? And why are they fine with a PT referral from a Chiropractor but will not consider direct access? How about this novel idea...let us do our job, we evaluate the patient and send the insurance company the POC for them to decide what they will or will not cover (they have no business making medical decisions, only financial ones). Our profession is now made up mostly of DPT's and we know more about our field of study than any referring!

      Posted by K Fox on 10/3/2018 4:26 PM

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