• News New Blog Banner

  • 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.