Insurers are increasingly contracting with third-party vendors of utilization management programs, or "UM," to administer the rehabilitation benefit. This toolkit offers an overview of challenges and opportunities for physical therapists in the commercial sector, strategies to mitigate the current and future impacts of UM use, and ways to foster cooperation between providers and UM vendors so that both parties benefit. The ultimate goal is the provision of patient-centered care at the lowest cost and maximum outcome. Download the Utilization Management Toolkit (.pdf).
What Is Utilization Management?
APTA Positions on UM
The History of UM
How We Got Here
Common UM Vendor Challenges Experienced by Clinicians
UM Systems Issues and Suggested Improvements
APTA Strategies to Address UM Issues
Member and Provider Strategies to Address UM Issues
Chapter Strategies to Address UM Issues
Physical Therapist Checklist
Tips for Successful Provider and Chapter Collaboration With Payers and UM Vendors
Templates and Calculation Tools
DISCLAIMER:This toolkit is available for general informational purposes only. It is not specific to the facts and circumstances of any person, organization, or practice. The information is not intended to provide legal advice or guidance. For help with your provider contracts, please contact your attorney and/or accountant to obtain advice with respect to any particular issue or problem.
The Payment and Practice Management Department, part of APTA's Public Affairs Unit, is responsible for issues in private health insurance, workers compensation, and automobile liability coverage. These issues include physical therapy coverage, payment, claims review, managed care contracting, and service codes. The department is APTA's liaison to private payers, medical review firms, and employer group health and workers compensation plans. Activities include providing assistance to members of APTA specialty sections and state chapters and working with payers and purchasers to address insurance issues. Contact us at firstname.lastname@example.org or 800/999-2782 ext. 8511.
The APTA gratefully acknowledges the contributions of the following individuals:
Peter Rigby, PT, MPH (Washington Chapter, chair of WAPTA Payment Committee)
Jackie Barry, CAE, (Washington Chapter, executive director)
Rick Katz, PT, DPT, MA (California Chapter, Private Practice Section Payment Committee, chair of CPTA Payment Policy Committee)
Tameka Island, MPA (California Chapter executive associate, professional affairs)
Mark Amir, PT, DPT, MPH, DipMDT (New York Chapter)
Lynn Steffes, PT, DPT (Wisconsin Chapter, Wisconsin Payment chair)
Anita Bemis Dougherty, PT, DPT, MAS (APTA staff, vice president of practice)
APTA gratefully acknowledges staff at the following companies for their assistance in identifying issues and corrective measures from the vendor perspective:
American Specialty Health