Good news from commercial insurer Aetna: Prior authorization is no longer required for physical therapy in five states. But will it stay that way? That could be up to the PTs themselves.
Recently, Aetna informed APTA that effective Jan. 1 of this year, providers in Delaware, New Jersey, New York, Pennsylvania, and West Virginia are no longer required to obtain pre-certification for physical medicine services.
APTA views the Aetna decision as a promising development and one that's in line with the association's ongoing advocacy to reduce administrative burdens, including excessive use of prior authorization at both the commercial and federal payer levels. Currently, APTA is leading an effort to support proposed rule changes that would improve prior authorization in a range of federal programs under the U.S. Centers for Medicare & Medicaid Services.
At the commercial level, APTA is focused on keeping lines of communication open between the association, payers including Aetna, and their utilization review and management contractors. That communication often includes education around the ways reduced administrative burden could be a win-win for payers and patients.
A Permanent or Temporary Change?
While it's welcome news for providers, APTA staff familiar with the commercial payer scene say that PTs in the five states should take a judicious approach to the new circumstances they face.
"It's important to remember Aetna's position, which is that it's dropping prior authorization requirements 'at this time,'" said Elise Latawiec, PT, MPH, senior practice management specialist at APTA. "If utilization increases at rates that are concerning to Aetna, they are likely to reinstate the requirements. Other companies have lifted prior authorization before in limited areas, only to bring it back when they saw a spike."
Kate Gilliard, JD, APTA director of health policy and payment, said that every victory around reduced administrative burden should be seen as an opening for the profession to show how care can be improved while leaving payers' bottom lines relatively unaffected.
"Beyond the fact that this is great news for PTs in those five states, it also offers a chance for the profession to show its commitment to sound clinical decision-making and responsible, appropriate care," Gilliard said. "Developments like this can lead to other, even bigger changes down the road if we approach this opportunity in the right ways."