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  • Kaiser Health Highlights Excessive Copays for Physical Therapist Services

    An April 22 article by Kaiser Heath News highlights the growing number of insurers and employers who classify physical therapy visits as specialty care, resulting in higher copayments for patients that often are equal to a specialist visit. The article quotes Matthew Hyland, PT, PhD, MPA, CSCS, president of the New York Chapter, and Justin Elliott, APTA director of state government affairs.  

    APTA's Fair Physical Therapy Copays webpage offers a variety of legislative resources, such as APTA model legislation and a sample letter to legislators, to help chapters in their fight against excessive copays. Examples of state strategies used by the Kentucky, Missouri, New Jersey, and New York chapters also are available.         


    • First of all I do not like high co-pays for my patients. And yet,on one hand are we not attempting to become recognized "specialists" via our reasoning for the DPT programs and fighting for direct access? Then in the same breath we are saying we are not specialists when it comes to co-pays? Am I missing something?

      Posted by Robert Oakeson,PT on 4/27/2012 4:05 PM

    • One problem we have as a "profession" is too much treatment using unproven interventions. Some of this goes back to the long standing habit of therapy 2-3x/week. Sometimes this is done "to keep the Dr. happy that ordered it and keep his business". "Endless physical treatments" for back pain is even mentioned by the American Board of Int Med Found as one healthcare resource that is wasted and can be cut. Not unlike physicians we must accept that we are part of the cost problem, not just victims of it. Folks with large co-pays only go, say once/week, and that's all most should need anyway!

      Posted by Ed Scott PT, DPT, OCS on 4/28/2012 7:39 AM

    • I believe if patients are charged speciality rates for physical therapy then the service should also be reimbursed at a speciality rate. Speciality Physician are reimbursed at a higher fee schedule than general interests. In most cases, I don't believe PT service reimbursement is at a speciality level. Moving towards Evidence based practice (EBP) will continue to help this profession evolve. A big thing is to determine why 75% of practicing PT's aren't member of the primary professional organization that is creating the next level guide to professional practice. Something that all PT's will be required to "live" by. The next level of professional standards.

      Posted by James McClure PT, MHs, ATC on 4/28/2012 10:37 PM

    • I disagree with Mr Oakeson and Mr. Scott. A major factor supporting lower copays for PT vs. MD specialists is the fact that an episode of PT care, under the most skilled and cost-conscious therapist, usually involves many more visits than a typical MD specialist intervention.

      Posted by Marvin Gross -> >NRcE on 4/29/2012 11:05 AM

    • Don't forget that, in general, if someone has a high copay, that means either the beneficiary, the beneficiaries employer, and/or the employer's Human Recource Dept./benefits broker either SELECTED BY CHOICE and/or BROKERED a less expensive policy. PT's....stop hating the insurance companies. It's our social responsibility to invest in the assurance of a robust health policy. The current demand for health insurance is for a lower cost premium in a health insurance market environment where fewer people are buying into it. People are using health insurance way different today than what it was originally designed for. I support the health care bill, because even if the 'individual mandate' gets thrown out for being unconstitutional, other components of the bill will incentivise people and states to buy into health insurance.

      Posted by David Bullock on 4/29/2012 11:13 PM

    • I’m sorry; I don’t usually chime in, but the last comment on “Social Responsibility”??? What is the "social responsibility" of the insurance companies? To pay retiring CEO's upwards of 20 million dollars while filing non-profit status to the IRS to avoid paying 35% corporate excise tax, something for which I am not allowed to do as a business owner? Continuing the tired argument that the cost of medical care continues to rise and that is the justification for 15-20% premium increases annually (unless you increase co pays, deductibles and reduce benefits) while payment to certain "specialists" like physical therapists has remained essentially unchanged for the past several years? Do people really still have patients who come in 3 times per week with a $35 co pay? Quick math....if the insurance company several years ago used to pay $75 for a visit to PT and the co pay was $5 that meant the insurance company reimbursed $70 and the patient $5. Does the insurance company still pay $70 with a $35 co pay? They do not. They are only responsible for $40. If a typical LBP patient walked in your door for 12 visits it might have cost the insurance company $840 several years ago, today that number might be $480 and you are to collect the rest from the beneficiary. That is if they don't have an ever more present $1000-$3000 annual deductible that has not been met. So please, spare me the “poor insurance company is caught in the middle” garbage. This math only applies to private practice as hospitals receive 2-3 times that on average from most insurance companies in their area for physical therapy and most of which (at least in my area) are able to waive co pays and portions of the deductibles to their employees who utilize all of their services by that hospital…something for which I thought might be encouraging over-utilization of services, seeing as we are all so concerned nowadays with waste, fraud and abuse. Why is it that hospitals are allowed to form partnerships with other hospitals yet small, independently owned practices are not allowed to form groups with other private practitioners to collectively bargain for better insurance reimbursement and/or more competitive healthcare premiums? Does it have anything to do with the "size" of the institution and its ability to hire lobbyists as to whether they are able to sit at the big table and negotiate? Of course it does. Some of the best hospitals are the biggest abusers of services, testing and lab work yet physical therapy continues to get picked on because people are apparently “using healthcare different today than it was originally designed for?" What way is that? To perhaps go to a physical therapist for 12 visits to get rid of their back pain? How selfish of them not to just go to their PCP, then get expensive medication and x-rays, then the orthopedist, then an MRI, then perhaps more medications and perhaps and injection and finally surgery and be out of their primary occupation for several weeks costing their employer thousands if not tens of thousands of dollars? Just how many studies are out there of how much less expensive physical therapy is for a variety of problems than just one visit to the PCP that snowballs into a free-for-all of health care practitioners? I have two articles sitting on my desk right now “Exercise vs. arthroscopic decompression in patients with SAI: a randomized, controlled study in 90 cases with a one-year follow-up” from the annals of rheumatic disease 2005 and “A randomized Trial of Arthroscopic Surgery for OA of the knee” from the NEJOM 2008. Both articles concluding that there is no additional benefit of the surgical intervention over optimized physical therapy. One more of particular interest is a Wall Street Journal article January 12, 2007 "A Novel Plan Helps Hospital Wean Itself off Pricey Tests." The synopsis is putting the consultation with physical therapy up front and eliminating the "extra steps in the medical maze" made for a much less expensive episode of care overall. As far as the "individual mandate" don’t turn this into a political debate. The same people who get free health care now will continue to get free health care in the future and will continue to abuse it, period.

      Posted by Darin McCarthy, MSPT, OCS on 4/30/2012 12:11 PM

    • Ed Scott, Robert Oakeson, david bullock, call me. I would guess you are employees and not employers. I would love to discuss the details with you. I unapologetically see my patients 2-3 times a week, and they get better, quicker and longer (no recidivism). I spend 20-40 minutes with old school hands-on manual therapies. Mr. McCarthy, AMEN! The patient is also a consumer who purchases a product (insurance). The consumer (patient and employer) is entitled to receive the product for which they pay through insurance premiums and employee contributions. I provide a service to that consumer, for which I expect to get paid what my time is worth and according to the level of complexity of problems that I solve. The insurance company’s job is to pay for the rendered services. So, what is the problem? A: The problem is “health care costs too much”. Who says it costs too much? Good question. Scenario A: the consumer (patient). How so? A: Patient cannot afford payments. Payments of what? A: copayments, deductibles and premiums. Who controls those? A: Insurance companies. Why then do the insurance companies increase their copayments, deductibles, and premiums on patients if the patient (consumer) can’t afford it? A: if you ask them (and I have) it is because health care costs have gone up and they need to raise premiums to pay for increased medical costs. To which I say NOT MINE! I have not increased my charges for 7 years, you know why? A: The insurance companies are going to pay me what they want to pay me anyway. The insurance companies can not say that they are raising prices because the medical field is raising costs, when it’s the insurance companies that control reimbursement. I make no apologies for my practices to an insurance industry that increases employer premiums annually, and then manipulates my reimbursement rates year after year resulting in reduced reimbursement and increased documentation. Furthermore, Obama-care in 2014 will see a large amount of insurance companies out of business because there are a limited few that will be contracted for the government health care exchanges. What we are seeing is an attempt by the insurance companies to stuff their mattresses now, not knowing what the climate will be like later. Folks we have this all backwards. We are not the bad guy here. But I fear our profession has drunk the cool-aid and we are apologizing and negotiating with the bully on the block.

      Posted by jack Parry on 5/1/2012 2:15 PM

    • Wow, it is disappointing to see so many of our colleagues totally out of touch on this issue. There would only be a handful of scenarios where an insurance company could be considered a friend to the PT world. One would be, that there was no longer such a thing as "in-network" vs "out of network" rates. This would allow us all to charge what we felt was appropriate and let the consumer decide what practitioners were worth their billed rate. The insurance company would pay a flat rate for the service, eliminating the hand cuffs of in network write offs, which effectively set our rates for us. This would be nirvana for any skilled practitioner. But that concept is fantasy land as of 2012, so don't hold your breath for that to happen. Not that it is completely far fetched. With some organization, we would follow the lead of the DDS profession, who figured out that being non-network providers was the way to go several years ago. Leaving the table scraps of in-network rates to the new graduates trying to get started. They obviously get it, and their financial statements reflect it. The second scenario would be that there was only ONE level of reimbursement for services provided regardless of whether the care is provided at an out-patient site, a hospital, or a POPTS. Mr. McCarthy eluded to this matter in his comments. Unfortunately, the "in-network" clamp is about to get so much tighter as the ACO world starts to take shape with only the biggest of fish getting to eat. If you are on the outside looking in at your neighborhood ACO, you are probably going to struggle significantly to maintain your referral base as they slowly defect into the safety of bigger ACO's that have their own PT services. It should be noted that the issue of equal compensation regardless of setting has been brought up in Missouri recently. See www.EqualPay4EqualServices.com for details. They quote on that site: "Health insurance companies pay private-practice physical therapy clinics 75% to 100% less than hospital-run clinics for the same services, and require patient co-pays that are up to five times higher than for hospital-based treatment.(1) Private-practice physical therapists assert that reimbursement and co-pays should be the same regardless of the setting in which physical therapy services are performed. Legislation was introduced to address this issue, but most PT's have never heard about it. Why you might ask? The proposed bill in Missouri highlighted the fact that the PAC for APTA had very split feelings regarding this issue and therefore didn't support the effort of private practice therapists in fighting this landmark piece of legislation because they were conflicted with the potential harm it might cause their hospital based members. Their inaction spurred the development of a private practice group: http://www.ptballiance.org/ to lobby and influence legislators solely on behalf of private practices. Since they are an annual membership group formed by various private practices, they don't have to worry about the mixed emotions of the APTA. If you are interested in donating to a PAC to help out patient PT causes, go to their site and check into it. It will be money wisely spent. And for those that still don't get it, just keep your head down, keep working hard, and make sure you are working for a clinic that has leadership that understands the bigger picture.

      Posted by Mark Callanen, PT, DPT, OCS on 5/2/2012 11:19 PM

    • I dont under stand much of any of this stuff but i am a 34 year. Old women that went to the doctor because of really sharp pains to my side . I went in to the hospital. Had test done They told me i am going to have to see a doctor that deals with blabladders. And thing like that so i Do he tells me i m going to have to have to have surgery because i have a mild stricture of the right urter. So they set up a surgery date i go in to the hospital to feel out all tje papper work. I get that done then they tell me that.my copay is 8500

      Posted by joy campbell on 11/22/2012 2:53 PM

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