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When it comes to commercial insurance payers, connections are important. Establishing relationships with corporate representatives makes it easier to call payer attention to problematic policies and promote access to physical therapist services that receive fair, equitable payment.

APTA's commercial payer advocacy begins with relationship-building but doesn't end there.

APTA staff review commercial payer policies to identify opportunities to engage with payers, collaborate with members to address clinical concerns, and proactively submit recommendations for policy changes. We also work closely with components through a network of the reimbursement committee leads, also known as payment chairs, to identify challenges and opportunities with local payers.

The hard work pays off. Here are a few recent highlights of what we've accomplished and what we're working on.

Coding Changes That Make Sense for PTs and Patients

The issue: The publication of the January 2021 Medicare National Correct Coding Initiative edits for physical therapy represented a big win for the profession, when the U.S. Centers for Medicare & Medicaid Services announced it would accept many coding pairs it had barred for use, or required to be accompanied by a modifier if they were used on the same day. APTA welcomed the announcement, as we had been advocating for exactly this kind of change for more than two years.

Next, it was the commercial insurers' turn to follow suit. These payers had initially incorporated the unwelcome edits and adopted policies that flagged claims with a 59 modifier. Those flags placed significant burden on providers to appeal and demonstrate that the modifier use was supported in the clinical documentation.

How we responded: When the initial, harmful edits were introduced, we met with commercial payers. But it soon became clear that they wouldn't be changing their policies until the edits were gone. So we focused on CMS.

In 2020, CMS responded to our advocacy — and the ongoing public health emergency — and deleted many of the edits, yet commercial payers didn't adopt the changes. Later in the year, CMS reinstated the edits, and we had to make our case once more. That's when CMS once again deleted the edits and made the deletions retroactive to Jan. 1, 2020. With the CMS policy in place, we turned to the commercial insurers.

Current Status: Our efforts are making a difference. We have received communication from Aetna, Humana, and Cigna that they are permanently deleting the problematic edits. Aetna and Humana are adopting the changes retroactive to Jan. 1, 2020, with Aetna automatically reprocessing denied claims and Humana reprocessing claims as requested by providers. We're now working with Aetna and Humana to ensure that providers know what they need to do to successfully get their claims reprocessed.

Telehealth — Not Just During a Public Health Emergency

The issue: In response to the public health emergency, commercial payers rapidly adopted temporary policies allowing coverage of physical therapist services when delivered through telehealth.

How we responded: APTA worked with payers and carefully monitored policy changes to ensure that PTs and PTAs were aware of billing requirements and of policy expiration dates. But we also viewed the temporary telehealth changes as an opportunity for payers to better understand the value of permanently covering telehealth service when furnished by PTs and PTAs. We opened communications with the five largest insurers to advocate for telehealth beyond the public health emergency.

Current status: Three commercial payers — BlueCross-BlueShield Tennessee, AmeriHealth Caritas, and Independence Blue Cross have already adopted permanent telehealth provisions for PTs and PTAs. APTA continues to engage commercial payers, monitor policy changes, and provide updates to members. In addition, APTA has developed template letters that may be used when advocating with local and regional payers.

Pursuing Noncoverage Decisions

The issue: Payers often consider procedures performed by PTs and PTAs as investigational and do not cover them.

How we're responding: APTA continuously reviews payer policies and challenges noncoverage decisions if we have evidence that supports the use of the procedure or intervention.

One recent example: We issued a letter to Anthem requesting reconsideration of exclusions identified in the AIM Specialty Health Clinical Appropriateness Guidelines Outpatient Rehabilitative and Habilitative Services Appropriate Use Criteria: Physical Therapy, Occupational Therapy, and Speech Therapy effective Dec. 1, 2020. While APTA supports some of the exclusions, others represent a deviation from evidence-based practice, and the references used to make the policy decision were not substantive. APTA provided current research on the use of select interventions and actively challenged the exclusions for gait analysis (instrumented), motion analysis, electrical stimulation, mechanical traction for lumbar disorders, and active therapeutic movements. Despite our efforts, the company has not made any changes to payment policy.

At the same time, we're helping members respond to immediate challenges by making it easier to appeal a denied code or request peer-to-peer review: We've developed templates that providers, clinics, and patients may use to challenge the exclusions. These can be found by scrolling to the bottom of the APTA Utilization Management and Utilization Review webpage.

Current status: There will always be differences in how payers view procedures and interventions. We know that we must remain on top of what's being denied and why, and be ready to counter those denials, when appropriate, with relevant evidence and policy research.

Payment Mechanisms That Wind Up Costing the Provider

The issue: Commercial payers are adopting payment policies that mandate the use of electronic fund transfers or virtual credit cards. In both instances the provider may incur an additional fee of up to 5% of the total payment. This has been a common occurrence with physicians and is now impacting physical therapists.

How we're responding: Our priority was to ensure that PTs were aware of this shift in order to work with providers on the best possible payment contracts, so we developed a provider guidance resource. We're also collaborating with other impacted stakeholders, including physician groups.

Current status: The use of EFTs and VCCs probably won't go away any time soon, but we believe that we can exert more advocacy impact by joining with other provider groups affected by these practices. At the same time, we're providing insight to members on defensive contracting that can minimize or even eliminate these payment provisions.

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