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  • Problems With Humana Claims? Let APTA Know

    Physical therapists (PTs) in several states are reporting claims difficulties with Humana's commercial and Medicare Advantage insurance plans, but more input from providers is needed.

    Recently, PTs from several states including Florida, Ohio, Kentucky, Louisiana, Virginia, and West Virginia have contacted APTA about Humana-related payment issues that include the retroactive application of the multiple procedure payment reduction (MPPR), further reductions to in-network providers' rates through the MPPR, confusion around Humana's approach to anatomical modifiers, and inconsistent application of the 59 modifier, with denials occurring even when the modifier was visible on the claim.

    In addition, the association has received reports of providers having difficulty accessing Humana personnel to discuss claims issues, and a lack of notification when policies and processes change.

    APTA staff have been in discussion with a representative from Humana to facilitate a resolution to the problems. As part of those efforts, APTA is urging members to contact the association by email at advocacy@apta.org, or by phone at 800/999-2782, extension 8511, to share any new or ongoing issues they've had with Humana.

    Need more information on retroactive claims denials and adjustments? Check out this APTA webpage. Also available: resources from Humana on postpayment recoupment, claims coding processing edits, and gaining a better understanding of other Humana processes.

    AGs From 37 States Call for Better Insurance Coverage for Nonopioid Pain Treatment

    Attorneys general (AGs) from 37 states have let the insurance industry know that the fight against the nation's opioid crisis won't be won unless health care providers are encouraged to prioritize nonopioid pain management options, including physical therapy, over opioid prescriptions for the treatment of chronic, noncancer pain. But that encouragement won't have much impact unless it's accompanied by payment coverage policies that make the nonopioid approaches more feasible to pursue, they write.

    In a letter to America's Health Insurance Plans (AHIP), the health insurance industry's trade association, AGs affiliated with the National Association of Attorneys General describe the opioid crisis as "the preeminent public health crisis of our time." The AGs say that while addressing addiction and recovery are crucial components in solving the problem, the issue must also be addressed further upstream—namely in the ways opioids are overused as a treatment for pain.

    "The unnecessary over-prescription of opioid painkillers is a significant factor contributing to [the opioid epidemic]," write the AGs. "When patients seek treatment for any of the myriad conditions that cause chronic pain, doctors should be encouraged to explore and prescribe effective non-opioid alternatives, ranging from non-opioid medications…to physical therapy, acupuncture, massage, and chiropractic care."

    The AGs write that the needed encouragement must come through insurance company incentives to follow a nonopioid treatment path. "Simply asking providers to consider providing alternative treatments is impractical in the absence of a supporting incentive structure," they write. "All else being equal, providers will often favor those treatment options that are most likely to be compensated."

    Besides helping to reduce the prevalence of opioids, nonopioid pain treatment is consistent with the science around pain management, according to the AGs. "Incentivizing opioid alternatives promotes evidence-based techniques that are more effective at mitigating this type of pain, and, over the long run, more cost efficient," they write. "Thus, adopting such policies benefits patients, society, and insurers alike."

    In a September 22 response, AHIP stated that its members "continue to expand and refine a comprehensive, multi-faceted approach to preventing and managing opioid misuse and related conditions," including "identifying alternative forms of pain management." The AHIP letter lists several member initiatives, including a push by Anthem to encourage providers to follow opioid prescription guidelines from the US Centers for Disease Control and Prevention. AHIP also states that it's working with some members on "exploring and improving access to non-pharmacologic pain treatments that have been proven effective in reducing pain."

    The AHIP letter also asserts that medical management—prior authorization, prescription tiering, plans that require "an evidence-based systematic approach to therapy," and the like—is 1 of the "most effective tools health plans have" in the battle against opioids, and has been mischaracterized as a "barrier" to treatment.

    "To effectively solve the opioid crisis, it must be addressed comprehensively by all stakeholders—from law enforcement and the justice system, to social services agencies and state Medicaid programs, to health care providers, pharmacists, health plans, and pharmaceutical companies," AHIP writes. "Only through collaboration and cooperation can we address—and solve—this crisis, and further improve efforts for prevention, education, intervention, and treatment."

    APTA's award-winning #ChoosePT campaign is aimed at informing consumers that physical therapy is an effective alternative to drugs for the treatment of pain. Housed at MoveForwardPT.com/ChoosePT, #ChoosePT includes a video public service announcement, as well as other targeted advertising and media outreach. Members can also learn more about the PT's role in pain management through offerings on PTNow, including a webpage with resources for pain management and an opioid awareness checklist.

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