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The world of commercial payers is constantly in flux, with changes happening on both large-scale and regional levels. Here is a roundup of the latest developments you should know about.

The PTA Differential

The 15% cut to payment for services by PTAs and occupational therapy assistants under Medicare was rolled out this year, and many commercial payers are weighing whether to follow suit if they haven't already. In addition to addressing the flaws at the Medicare level, APTA staff and member volunteers are educating commercial payers on the potential harm to patient access that could result from implementing a differential.

Iowa and South Dakota racked up a differential win (for now at least).
APTA Iowa and APTA South Dakota, in collaboration with APTA, were successful in advocacy with Wellmark, which decided to postpone implementation of a differential system until 2023. PTs are still required to attach the CQ  modifier to claims to indicate when services were provided by a PTA, but no payment reductions will be triggered. Discussions with Wellmark around the 2023 implementation are ongoing.

Cigna is moving ahead with the pay differential.
Cigna announced that it will implement a 15% pay reduction, in line with the Medicare differential, beginning Oct. 15 for all states except Texas, Kentucky, Colorado, and Ohio, where the reductions will take effect Nov. 1. Providers who contract through American Specialty Health, which will not be implementing the CQ or CO modifier, will not be affected by the differential decision. APTA will be meeting with Cigna to discuss this and other recent decisions, their impacts, and mitigation.

(Want more information on how to properly code for the differential? Check out this APTA Magazine article, "How to Apply the New CQ Modifier.")

Multiple Procedure Payment Reduction

The use of MPPR among commercial payers is not new, but there has been a recent uptick in implementation, with Blue Cross-Blue Shield in Massachusetts, Michigan, and Nebraska adopting the policy beginning Sept. 1.

An explanation of MPPR and a link to an APTA resource that can help you calculate payment is available at the APTA Multiple Procedure Payment Reduction webpage.

Visit Limits and Capitated Payments

Even though arbitrary restrictions on treatment are not in the best interests of patient-centered care, commercial payers continue to roll out new rules.

Cigna will adopt new visit limits.
As part of revisions that include the shift to the PTA differential described above, Cigna also is implementing a four-unit-per-visit limit on claims for physical therapy, occupational therapy, and chiropractic. Simply put, beginning Oct. 15 in all states — except for a Nov. 1 startup in Texas, Kentucky, Colorado, and Ohio — the portions of a claim greater than four 15-minute units of rehab services per patient, per day, per provider, will be denied as not medically necessary. Cigna is implementing an exceptions policy based on medical necessity review with appeals rights. APTA will be meeting with Cigna to discuss impacts and mitigation.

Highmark Pennsylvania will cap payment rates.
Highmark Blue Cross Blue Shield of Pennsylvania will be implementing maximum payment rates for PT evaluations and treatment visits. PTs will continue to bill with CPT codes but will only be paid up to the maximum rate. Any charges over that cap will be zeroed out on the remittance. In-network providers should have received a special bulletin from the company.

Questions about commercial payers? Email advocacy@apta.org.


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