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  • APTA Survey: PTs Say Administrative Burdens Delay Access, Affect Clinical Outcomes

    Think that administrative burdens are hurting your ability to provide the best possible care? You're not alone: results of a recent APTA survey of physical therapists (PTs) nationwide reveal that nearly 3 in 4 believe that overreaching documentation and administrative mandates negatively affect patient outcomes—and 8 in 10 point to excessive requirements as a contributor to clinician burnout.

    The results are now part of an infographic that helps with the association’s efforts for legislative and policy changes to rein in excessive requirements around areas including prior authorization and claim denial appeals. Among the findings:

    Prior authorization requirements delay care and affect clinical outcomes.

    • Three quarters of respondents said that prior authorization requirements delay access to medically necessary care by 25% or more.
    • 72% of survey participants estimated that they wait at least 3 days for a prior authorization decision from an insurer.
    • Just over 1 in 4 respondents said that the wait time is usually more than a week.
    • Approximately 3 in 4 PTs agreed or strongly agreed that prior authorization requirements negatively impact patients' clinical outcomes.

    Claim denial appeals are time-consuming (and often contradictory).

    • 40% of respondents told APTA that payers who say they don't require prior authorization later deny approximately 25% of claims for lack of prior authorization.
    • 65% of PTs said that it takes more than 30 minutes of staff time to prepare an appeal for 1 claim.
    • When it comes to rates of claim denials, appeals, and final dispensation, respondents estimated that 13% of filed claims are denied; of that 13%, 66% are appealed. And in the end just over half of the appeals—52.34%—are overturned.

    Administrative burden is adding to cost—and burnout.

    • The survey revealed that large percentages of both front desk staff and clinicians spend more than 10 minutes per patient requesting approval for continued visits, ranging from 64.6% of clinicians working with Medicaid fee-for-service beneficiaries, to 77.3% of front desk staff requesting continued visits for Medicaid managed care patients.
    • More than three-quarters of facilities—76.5%—reported that they've had to add nonclinical staff to handle administrative burden.
    • 85.2% of respondents agree or strongly agree that administrative burden contributes to clinician burnout.

    As for what changes would make the most difference, just over half of respondents believe that standardizing documentation requirements would be a big help. Other popular adjustments were elimination of the requirement for the Medicare plan of care signature and recertification (38.8%), standardization of coverage policies across payers (38.1%), unrestricted direct access (36.1%), and standardization of the prior authorization process (36%).

    "APTA has long argued that excessive administrative burden negatively impacts care—what's important about this survey is the consistency of responses and the level of shared perception among PTs who experience this issue every day," said Kara Gainer, APTA director of regulatory affairs. "Administrative burden isn't a nebulous issue for providers—it is a very real barrier to delivering care, with identifiable pain points and very specific areas in need of change."

    The association continues to place the reduction of administrative burdens high on its advocacy list and has again identified the issue as among it 2019-2021 public policy priorities. One recent opportunity: a request for information (RFI) from the US Centers for Medicare and Medicaid Services (CMS) on reducing administrative burden. APTA will provide comments by the August 12 deadline and has made it easy for individual clinicians to submit comments by way of a template letter that can be personalized to suit specific circumstances. APTA is also developing a template letter that can be used by patients and will post a link to it on the association's regulatory "take action" webpage.

    At the same time, a legislative advocacy opportunity emerged in the form of a congressional bill aimed at improving access to health care for older Americans through, among things, reducing administrative burdens on providers. Known as the "Improving Seniors' Timely Access to Care Act of 2019," (H.R. 3107), the bill was introduced into the US House of Representatives by Reps Suzan DelBene (WA), Mike Kelly (PA), Roger Marshall (KS), and Ami Bera (CA). APTA staff will add information to the Legislative Action Center in the coming weeks for members to use to advocate in support of this legislation.

    “Current prior-authorization programs hinder patient access to medically necessary services and must be modified,” said Katy Neas, APTA executive vice president for public affairs. "But this is just 1 element of the wider administrative burden issue, and APTA will continue to advocate for change on multiple fronts."


    • In addition to authorization and denial administrative burden, larger institutions are laying on the paperwork and documentation burden with unwieldy EMR "checkboxes" required for therapists to wade through. Therapists are spending more and more time on a simple daily treatment note due to the ridiculous requirements from management/system processes of "necessary/required" documentation.

      Posted by Jennifer Hundt on 7/3/2019 6:30 PM

    • The administrative burden that we and the rest of health care providers also face would be greatly relieved if we had a single-payer, universal financing system for health care in the United States as they have in Canada. Single-payer would standardize documentation requirements and coverage policies and allow us to concentrate more on taking care of our patients. Then our complaints can all be directed to one source instead of multiple payers in a huge hairball of a dysfunctional insurance-based system. Furthermore, our patients do not care about who is insuring them as much as they care about who is treating them and their freedom to choose their caregivers themselves. With universal health care, their choices would be universal. As a professional association, we should move to support universal, single-payer health care in the United States.

      Posted by Stephen Small on 7/3/2019 7:23 PM

    • I run the front office at Evolve Physical Therapy in Sherwood, Oregon. Our clinic has 3 practicing physical therapists. Right now we have 27 active authorizations going. I had to design a spreadsheet to keep track of patient name, insurance company, auth company, number of visits/units authed and the date ranges! Talk about administrative burden - that does not even include the time it takes to obtain the auths and educate the patients on how they work! Thank you for advocating for us on this topic!

      Posted by Brittany Abeyta on 7/3/2019 7:32 PM

    • If this is what you like and want more or be sure to vote for any democratic (socialist, Medicare’s for all) candidate.

      Posted by Bob Moynihan on 7/3/2019 8:17 PM

    • A larger impact is the 45 minute limit on treatment. Another is the default to use of PTA's in treatment because reimbursement is so poor administrators will do anything to save money. Let's face it, seniors have multiple problems that require time to treat. For that matter, 45 minutes is far too short a time for nearly all our patients. The limitation has devolved treatment to exercise and maybe US or TENS. As a profession, we can't be effective under the limitations imposed by CMS and many third party payers. As a result, many of our previous MD supporters are recommending patients see other providers because PT isn't as effective as it once was. That is the important conversation that needs to be the center of every conversation in this profession until we regain our ability to be effective. As an aside, I assume that only 75% of respondents described excessive admin. burdens as having a neg. impact on patient care because 25% of the respondents have practiced for a short period of time and have never known another practice paradigm. Shockingly, the altered treatment paradigm began in 2005. Dr. Brian P. D'Orazio PT, DPT, OCS

      Posted by Brian P. D'Orazio on 7/3/2019 10:52 PM

    • Due to excessive time and costs of insurance and administrative burden, we now only accept MC on assignment. We are out of network with all other insurances. Patients pay us privately up front, and we submit EHR/Clearing house billings. If we get paid, we refund their payment to them. If they get paid, they keep the check. It has worked well. We are close to giving up MC for the same reasons. We find clients will pay for what they believe to be excellent care with excellent outcomes in short or reasonable time frames, with more time spent per session, and less sessions overall. Has kept us in business. 40 years this year. Good luck to all!

      Posted by Larry Greeenberg on 7/3/2019 11:36 PM

    • I spend 2 hours per night attending to documentation after I leave work 6 days per week.

      Posted by steven login on 7/3/2019 11:38 PM

    • A study should be done on how many PTs and other health care providers are retiring early as they just dont want the paperwork hassle anymore. Many are still volunteering in free clinics(as long as they keep their licenses), where documentation is much less and there is no insurance to deal with, which leads me to believe they arent burnt out from actual patient care.

      Posted by Rita J Newton on 7/4/2019 9:31 AM

    • It would be beneficial for the APTA to advocate for standard authorization processes across all insurers due to the burden it places on all practices. There is significant strain on smaller private practices that are forced to have employees wear many hats, and takes away form patient care.

      Posted by James Seykot on 7/4/2019 10:30 AM

    • Hoops, hoops and more hoops to jump through. I have been licensed in our field of PT for 28 years and have been in private practice for 21 years. Over the years I have seen decreased reimbursement with increased demands on paperwork and authorizations. At this point I truly feel as if insurance companies are just throwing things at us just to cause technical denials. I had over a dozen instances of insurance companies giving us incorrect information leading to uncovered services over the last year. We keep documented records of the time of call, person who we speak with and any information/auth numbers given to us. Most of the time insurance companies will use that information to pull the call and overturn their judgment. The point is their own employees will give out incorrect information. We spend hours on the phone just to get one auth/patient benefits. Sometimes, we are on hold for over an hour and get disconnected by the company. Then there are companies like Rehab Provider Network who can stall payments for years, yes years! What a run around! We are a small Medicare certified ORF, too small to fight insurance companies so we continue to jump through the hoops to make sure our patients get the best possible care we can give them.

      Posted by Robert Runkel on 7/5/2019 2:47 PM

    • Agree with the previous comments. Additionally, the fact that insurance companies are not required to be transparent with what rationale determines their determination of "Medically Necessary" and they do not reveal the credentials and written documentation of the person making the determination is highly suspect. This information should be required, and should be part of each patient's insurance packet so that the consumers are aware of what their insurance company actually covers.

      Posted by Alison on 7/5/2019 4:54 PM

    • YES, Lots of hoops and waste... what's more, we are routinely finding in our analyses that private practices are actually losing money on 25% or more of their total 3rd party payer volume... cases they should not be pre-auuthorizing or even accepting. They would in fact earn more by reducing service volume, space and staff. Both payer and provider business decisions compromise value creation financially and functionally for all parties. Time to rethink everything and realign interests strategies and operations to act more like competitive businesses and less like entitled practices...

      Posted by Bob Wiersma on 7/6/2019 2:44 PM

    • Thank you for making this a national priority. In my practice (MD), our greatest issue is with commercial payors like UHC and Cigna/ASH who reimburse more poorly than Medicare/Medicaid - while requiring more unique processes to authorize care. I can't imagine that the staffing required for insurances to track these processes is cost efficient, but they have the advantage of scale that individual practices typically do not. I will be following and supporting APTA's efforts on this closely. I hope that other provider organizations who face similar challenges can be unified.

      Posted by Shannon Murphy on 7/8/2019 9:16 AM

    • I own a single practitioner private practice & see only ages 0-24 months. This means that sessions are one-on-one hands-on. I love my work, even after nearly 45 years. But my income is laughable and reimbursement has stagnated for many years. I cut down to 3 days a week of patient care but I have to put in1-2 additional days for hoop jumping. It seems that each time I get comfortable with which payor requires what, they change the rules. It may drive me to retire though I would rather continue caring for our youngest population.

      Posted by Jacqueline Mast on 7/8/2019 5:30 PM

    • I left home health after 12 yrs. I was tired of the long days,even though our company paid all the document time. I traveled for awhile. Then returned home to search for a good fit in the out patient setting. I was not happy at the new market. 30 min visits 40 min. Visits, and doing charting one emr.and not getting paid for the time. I now work where we have 45 min visits, although it is challenging,we are getting it done,and doing charting at the end of the day,and getting paid. I miss the 1 hr treats. We need to fight for fair treatment for our patients and be paid for services that we feel are effective. So tired of the billing process.

      Posted by Susan Herman mpt on 7/8/2019 10:12 PM

    • I am a home health PT and have been for the last decade. In that time, I have steadily seen the amount of paperwork seemly take precedent over patient treatment time. Since there is no regulation on how much paperwork a particular agency/company can require, it can therefore be doled out irrespective of who has to fill it all out. What I find happening is that companies begin developing their own policy for paperwork and thus begin to make up their own paperwork in addition to what is actually required federally or state. This is done because there is nothing to regulate or put an end to the amount of paperwork any one agency can require. Some agencies will take a page from their evaluation form and use that one page to develop a new form even though it is still included and required that it be filled out in the original evaluation packet that it came from-only now that separate form is called as an actual example a ‘14-day reassessment’. When asked what that even is, I am told it is a company policy not a federal or state requirement. There is no accountability for the endless amount of paperwork that is added. In addition to amount of paperwork, this paperwork is often repetitive in nature. Each ‘required’ form asks for the same info over and over just in different places. While some companies/agencies pay for paperwork time, in my experience most do not. Perhaps these are ones that abuse and add to this administrative burden. If no one has to pay for it what is to stop an agency from continually adding more. Since paperwork is continually added, with that comes more training sessions and trial and error time periods. This creates a culture of administrative micromanaging. When someone is micromanaged, it creates an offensive and judging feeling as well as adding to a contentious work environment. So many PT’s are leaving or not going into the health setting for exactly for this reason. With the episode of care being cut from 60 days to 30 days, this added yet more paperwork and as mentioned above some agencies require a ’14-day reassessment as well as ‘Functional Reassessment/30-day summary form; to go along with it. Again, since there is no regulation on what kind and how much paperwork an agency can add… they do. It becomes a game of how can we avoid being sued…. we can just keep adding more and more paperwork and the therapist will do it. This culture is creating burn out; a mental health issue. Clinicians experience resentment, stress and anxiety. In the article called: 'Burn-Out' Is Now a Legitimate Syndrome According to The WHO. Here Are The Symptoms by CARLY CASSELLA 29 MAY 2019 “Workplace 'burn-out' has become such a serious health issue in the modern age, it's now been reclassified by the World Health Organization. Within the agency's widely-used manual, known as the International Classification of Diseases (ICD), burn-out will be officially listed: not as a medical condition (as some initial reports have wrongfully stated), but instead as an 'occupational syndrome'. Being completely overwhelmed with administrative situations, patient care can begin to be lost. I have heard fellow therapist’s say I'm not going to do anymore start of cares because the OASIS is long enough not to mention all the agency’s added paperwork. I have had so many agencies send out reminder notices that it is a physical therapist’s responsibility to do the start of care because if not it then it falls on the nurses which in turn creates burn out in another field. Just recently, I was required to turn in a paragraph summary on a patient’s status because I submitted an authorization to an insurance for more therapy. I asked why to the extra summary and why the insurance company just doesn’t look at the myriad of paperwork that I am required to turn in to see the patient’s status. I was told what I already knew….that the insurance company doesn’t want to sift through all the paperwork I filled out. It is easier for them to have me yet do more paperwork and submit an concise summary of all my paperwork. This has to stop. A good example of this is, how many times have you gone to your doctor’s office for a medical exam and you fill out all that paperwork as a new patient before you go in to see the MD and then when you walk in they ask you the same questions that you just spent 20 min filling out. It is a waste of time and I question just how much of it is actually read. EMR checkboxes have potentially made this issue worse. It is believed that it is easy to just check off boxes so why not add more and more checkboxes.

      Posted by Mario Moncada, PT, DPT on 8/13/2019 1:58 AM

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