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  • APTA Working for You: Commercial Payer Updates, July 2019

    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.

    The results of an APTA survey on administrative burden are in
    APTA highlights the results of a 2018/2019 survey on administrative burden in a new infographic. The survey revealed significant concerns from PTs and PTAs, particularly around the impact excessive requirements are having on clinical outcomes. A summary report on the findings is also in the works.

    The survey and infographic will be the subject of a presentation on administrative burden at the 2019 APTA Insurers' Forum. APTA encourages members to review the infographic and summary (when it's released) and use the resources in discussions with payers and other stakeholders.

    OSHA responds to APTA by affirming the PT's role in first aid
    In response to a meeting with APTA and our subsequent request for clarification, the US Department of Labor Occupational Safety and Health Administration (OSHA) issued a statement affirming that in workplace injury incidents, soft tissue massage is considered first aid for recordkeeping purposes, regardless of whether the health professional providing the treatment holds a certification in Active Release Techniques (ART). Details on the clarification, which is good news for physical therapists, can be found in this PT in Motion News story.  

    Use of third-party administrators is growing—and staying on top of the changes will require communication
    APTA continues to track the increased use of third-party administrators to manage the physical therapy benefit as national payers implement systems regionally with the intent to include all states and lines of business over time.

    APTA and its chapters collaborate and coordinate efforts to mitigate adverse patient impacts and provider administrative burden related to utilization management (UM) vendors. At the same time, the association seeks to develop a working relationship with payers and UM vendors to advocate for members when issues arise. Those efforts are strengthened through members' ongoing communication with APTA. Download this step-by-step guide for tips on when and how to report new or significantly changed UM programs.

    APTA's work with eviCore is increasing provider access to information
    Utilization management firm eviCore has made it easier for providers to find provider engagement staff assigned to their geographic area. The list, available as a pdf document on the eviCore website, is among the resources available on the company's "training resources" webpage.

    Front-end claim edits are on the rise
    Front-end edits—when a payer automatically denies a claim with a certain profile, forcing the provider to appeal the denial and provide documentation supporting the appeal—are being implemented by several payers and third-party administrators. For PTs, the most frequent trigger for a front-end edit is the use of the 59 modifier.

    APTA has taken several steps to address this issue, including asking the US Centers for Medicare and Medicaid Services (CMS) to remove edits associated with codes commonly used by PTs, engaging commercial payers in discussions about challenges associated with these edits, and providing resources to providers, including this infographic on use of the 59 modifier. APTA urges providers to consult with the association about appropriate use of the 59 modifier, and to follow through with the appeals process if documentation supports its use. Appeals can make a difference—Aetna has already indicated that if the turnover rate on appeals is high for a particular type of claim, the front-end edit will be removed.

    An APTA-sponsored session at a self-insurers' conference focused on the PT's role in population health
    APTA member Michael Eisenhart, PT, presented an APTA-sponsored session titled “Population Health: How Physical Therapists Can Help Your Employees” at the 2019 National Council of Self Insurers annual conference in June. Eisenhart's presentation showcased the role of physical therapy in the workplace and emphasized its potential for employers who self-insure their workers' compensation programs.

    Workers' Compensation programs are evolving in positive ways
    APTA has observed a greater recognition among workers' compensation (WC) programs that physical medicine not only helps address musculoskeletal issues, it also promotes patient participation in recovery and self-management and reduces the risk of reinjury. While overall injury rates and frequency have been declining, the percent of claims with physical medicine involvement have increased by 13%.

    Ohio is an example of the how this shift is playing out. In 2018, the Ohio Bureau of Workers’ Compensation mandated 60 days of conservative care before the authorization of lumbar fusion surgery. Accordingly, a national WC third-party administrator reported a rise in nonsurgical physical therapy referrals, with an attendant drop in surgical referrals—from 11% in 2017 to 5% in 2018.

    New York is also embracing the value of physical therapy in WC. The New York Workers’ Compensation Bureau (NYWCB) adopted a revised fee schedule in October 2018 that became effective on April 1, 2019. NYWCB increased the relative value units (RVUs) to 18 for evaluations and 15 for reevaluations. The bureau also raised RVUs from 8 to 12 for follow-ups. The net result of this change, plus the fee schedule increase, will result in payment increases. APTA's New York Chapter provides a detailed accounting of the changes.

    APTA, AOTA, and ASHA create a guide to assessing habilitation and rehabilitation benefits
    APTA, together with the American Occupational Therapy Association (AOTA) and American Speech-Language-Hearing Association (ASHA), collaborated to create a guide to assessing habilitation and rehabilitation benefit adequacy that emphasizes transparency, access, and affordability. Available on APTA's Essential Health Benefits webpage, the guide forgoes offering a laundry list of specific benefits in favor of establishing a set of principles that the associations believe lead to appropriate coverage of habilitative and rehabilitative services.

    Anthem's transition to a new UM vendor in 13 states is still on, but delayed
    Anthem Blue Cross-BlueShield is moving ahead with its use of utilization management (UM) vendor AIM Specialty Health in 13 states, but technical issues have delayed implementation.

    Providers who bill Anthem in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio, and Wisconsin can still expect to be required to use the new vendor in the near future—Anthem says it will update providers toward the end of July on when actual implementation will occur

    In the meantime, APTA urges providers in the impacted states to participate in vendor-sponsored training available through the AIM Rehabilitation Provider Portal. If you experience difficulty enrolling in training or other problems, inform your APTA chapter.

    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. Have questions or want to make your voice heard in local, state, and national advocacy? Email advocacy@apta.org.


    • Great work on the administrative Burden handouts/summary. To those that criticize APTA's work on Payment and Regulations- shame on you! APTA sent out close to 16,000 surveys to members and only 1,617 of you took the few minutes needed to complete it. Imagine the power if this report represented over 10,000 of us. I am becoming more and more frustrated with those that jump on APTA's back for "doing nothing to help them" when they can't even take a few minutes to respond to a survey that is being done directly for our benefit. Thank you APTA for all that you do on our behalf.

      Posted by Amanda Somers on 7/24/2019 7:10 PM

    • I posted this on another article but it's relevance extends to this article as well so here goes. Is it just me or is the craziness growing? From above: "... physical therapists are making an overall difference in patients' lives." Well, duh, if we didn't, what is the purpose of our profession? What is with the insecurity of this profession that we need to keep trying to prove what is already blatantly self evident. Other articles put out by APTA are citing a greenroots cry from providers for relief from administrative burdens. But this article, in juxtaposition, is asking for more and more data. Do they realize that data gathering is an administrative burden? How much data is enough? We have gathered more and more data and evidence for how effective physical therapy is, yet our reimbursements keeps going down, down, down and the workload to obtain that reimbursement keeps going up, up, up. Don't they realize that this is just a game? Well, let me explain it. It's a game. There are two players. We, the providers are one player. They, the payors (when they are the insurance companies or government equivalents rather than individual patients) are the other player. One doesn't have control and the other does. One is motivated as much by altruism as by profit while the other is motivated exclusively by profit and largely directed by individuals with sociopathic tendencies (which is not opinion or belief but factual and based on evidence from psychological scientific studies) One has a limited amount of time to engage in this game since this player's time is largely engaged in treating patients, the source of their profit, an activity which cannot be ignored if the revenue stream is to continue. The other has unlimited time to devote to maximizing their profits because that's their primary task. The latters' profits are achieved in three ways: (1) by reducing taxes through influencing government via financial means (check), (2) by raising premiums to customers (check), and (3) by reducing reimbursements to providers (check). They are successfully doing all three while we are unsuccessfully attempting to stop reductions in reimbursements. They are pro-active while we are forced to be reactive in response. They make the rules. We follow the rules. They change the rules as frequently as needed to increase their profits. We have to scramble to keep up with, interpret, and comply with the rules to minimize the loss in our profits. Can you see how this is an unwinnable game for us given we continue following the losing strategy we have followed for all too many years. We will never, repeat NEVER be able to generate sufficient quality and quantity of data to make the payors suddenly change their minds and give away THEIR profits to increase OUR profits. Ain't gonna happen, no way, no how. They are not Santa Clauses who are going to reward you for a job well done. They are greedy business people who will hide behind a pretense of operating for the general good while in reality only operating to benefit themselves. They operate purely in self interest and nothing else. Let's take one example from above. Evicore. I don't know about others but Evicore has been a bane to my existence and a bane to the welfare of my patients. Evicore's CEO has been getting wealthier and wealthier while my income per patient has shrunk and my workload per patient has grown. Evicore has been acquired by Express Script. Express Script's CEO is even wealthier than Evicore's. Express Script is owned by Cigna, the insurance company. Cigna's CEO is even wealthier than Express Script's. Google "stock symbol CI" and you will find the stock chart for Cigna Corp. Click on the far right where it says "Max" and you will see the historical stock prices of Cigna. Note the exponential rise of the stock price. That means that the CEO, executive board, and stock holders are becoming phenomenally wealthy. And guess who's funding that growth in wealth? We are! I don't know about you but I'm personally resentful of these people unfairly taking more and more of my hard earned money. Why do we continue to play along with them? Can you figure out how to change the game (which is really the only way you can win)?

      Posted by Brian Miller on 7/24/2019 9:42 PM

    • I’ll jump on the bandwagon when it comes to Cigna. They reimburse a ridiculous max daily allowance of $65/visit! This is absurd and completely unacceptable, yet we fear upsetting our referral sources by choosing to remain out of network. I am opting to go out of network, but this will mean I will have to diligently educate my referral sources regarding my dilemma which risks creating the impression that “it’s all about the Benjamins.” I can only hope that common experiences among referral sources will garner their empathy and understanding to the extent that our professional relationship will be sustained. IMHO, I feel we therapists, are collectively morally obligated to refuse to accept financially nonviable provider agreements. We also need to demand greater transparency from insurance companies that hide the ball on an ongoing basis in a myriad of ways.

      Posted by Bill on 7/27/2019 9:27 AM

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