Payment
Current Payment News
July 2024 APTA State Payment Forum 
Yvonne Swanson represented APTA RI at this forum in Kansas City.
Click here for the powerpoint during the forum.
June 2024
Collecting Data on the Impact of NHP's prior authorization - please help
Neighborhood Health Plan of Rhode Island’s recent decision to add prior authorization and utilization management practices to PT, OT and SLP has greatly impacted providers and practices. The APTA RI Payment Committee would like to collect data that tracks administrative burden on clinical and administrative teams to use in future advocacy regarding this decision. Please consider having your team complete this. To also make an impact, ask your patients affected by this to send a letter to NHP.
Please find attached 2 important documents from the Payment Committee to support all Providers and Practices impacted by NHP’s decision to add prior authorization and utilization management practices to PT, OT and SLP.
- ‘PA/Authorization Tracking Sheet’ for practices to track the impact of administrative burden on their clinical and administrative teams and the resultant patient outcome.
- Spreadsheet to complete
- This sheet provides an easy-to-use tool that standardizes the data collected and as a result, can be sorted and utilized by APTA RIat a future date to support advocacy efforts
- Any data a practice can share, even if 10-20% of their patients, will have a significant impact.
- Return to APTA RI Payment Chair - Yvonne Swanson
- ‘Patient Advocacy Letter Template’ We highly recommend that Practices/Providers provide this template to patient’s who wish to share their personal concern and experience with the addition of Prior Authorization by NHP (barriers to access, delays, letters from Evolent about their PT and denials).
Effective June 1st, NHP will require prior authorization (PA) for PT/OT/Speech services:
As most of you know, PT/OT/Speech are being required to secure prior authorization (PA) under a new policy adopted by NHP utilizing Evolent Health as the administrator. Despite our advocacy efforts underscoring the value of rehab services and total cost of care savings, NHP's decision stands.
To ensure readiness, NHP has announced Provider Training Sessions via Evolent Health on May 22nd, 24th, and 30th specifically for the Physical Medicine Provider group. Meeting details listed here.
APTA RI is urging all impacted providers to:
- Attend one of the above listed meetings
- Come with specific questions
- Follow up IN WRITING with those same questions
While we don’t believe PA is necessary and the increased administrative burden has a significant impact on practices, it is critical that therapists understand how NHP’s PA system will work for not only a smooth transition, but to ensure our concerns are built on a solid foundation of provider knowledge on the new policy rules.
Additionally, APTA RI advises practices to PLEASE monitor their experiences with Evolent and prior authorization as this policy rolls out. For any inquiries or assistance, please don't hesitate to contact Yvonne Swanson.
April 2024
Adapted from March 22, 2024 APTA Friday Focus – Payment:
Change Healthcare Cyberattack Updates
Providers and patients continue to deal with the effects of the massive Feb. 21 cyberattack, the largest health care hack to date. Here's a roundup of useful information, including links to Change and UnitedHealth resources, HHS announcements, media coverage, and more.
Aetna Launches PTA Differential
After putting the move on hold for three months, the insurer implemented the reduction March 1.
Spending Deal Reached: Includes Some Relief From Fee Schedule Cuts
The package includes a 1.68% boost to the fee schedule but falls short of totally eliminating the cut to dozens of providers
Going Straight to the Source: Direct-to-Employer Services
From APTA Magazine: Direct-to-employer physical therapy companies take out the insurance middleman.
February 2024
NHP partnered with Evolent Health to manage services for PT, OT, SLP through National Imaging Associates (NIA)
- RI APTA Payment Committee is engaging with NHP against these changes that add administrative burdens to providers and ultimately impact access to care.
- Reach out to Yvonne Swanson, RI Payment Committee Chair with your concerns yswanson@highbarhealth.com
Know your rights! Prior Authorization Win: CMS Finalizes Tighter Payer Rules
Review of Policy Key Points:
- All services under Evolent’s solutions will require prior authorization as of April 1st.
- Verification for rendering services for new and continued care must be obtained by signing in on Evolent’s website, or calling Evolent at 1-877-469-7949
- FAQ’s click here and Provider Education Webinars are scheduled for are March 27, March 29, and April 4, 2024
Want help calculating Medicare payments? …APTA’s Fee Schedule Calculator for 2024 is now available!
2024 Fee Schedule Calculator Now Available to APTA Members
“Great tool that’s easy to use!”
Reflects where payment stands as of Jan. 19th. If Congress makes changes, the tool will be updated.
Medicare Physician Fee Schedule cuts of 3.4% continue….We need your help TODAY!
Congress kicked the can down the road in January giving ALL stakeholders more time to voice their concerns to local legislators about the impact of these cuts.
Support H.R. 6683 through the APTA Patient Action Center or Legislative Action Center. It’s fast and easy!
November 2023
Local Payor Updates:
Huge win! Blue Cross Blue Shield Increases max allowable per visit! : Sign in to your BX account for detailed description
Blue Cross Blue Shield Removes referral requirements effective Jan. 1st 2024 for PT and OT services under the following products:
- All Medicare Advantage Plans, Blue CHiP Direct Advance, Blue CHiP w/Flex, Network Blue NE, Network Blue NE Options and Blue Choice NE
Summary of CMS' Physician Fee schedule and final rule adapted from APTA 2024 PFS and Final Rule update
- Fee schedule ~3.4% reduction to the conversion factor. – APTA advocating with congress to reduce in full to keep PT's whole. $240.00 deductible, Threshold for use of KX modifier for PT/SLP $2,330.00 , Medical Review Threshold remains at $3000.00 through 2027
- CMS' Quality Payment Program MIPS Rule:
- Incorporates a new APTA recommended MVP MIPS Value Pathway based on musculoskeletal care with a new cost measure PTs can use on low back pain.
- CMS will no longer exempt PT practices of 16 or more clinicians from the promoting interoperability category which requires practices to have a certified electronic health records technology in place for at least 6 months of 2024. This change does not apply to hospital based clinicians and clinicians in small practices
- Telehealth: No changes in codes. Under final rule PT's can participate in TH in private practice settings by uing the same 95 modifier.
- PTA supervision requirements – remain at "direct supervision" for 2024 in private practice settings. The final rule extends virtual supervision of PTAs and OTAs through the end of 2024, and finalizes a general supervision-only requirement for PTAs performing remote therapeutic monitoring regardless of setting.
- New Caregiver Training Codes: Allows for PT's OT and SLP's to bill for providing training to caregivers when a patient with a functional deficit is not present. They are not subject to MPPR and cannot be used with Telehealth. 97550 initial 30 min. , 97551 ea. Additional 15 min. , 97552 Group
- Also in the final rule, CMS responded to a criticism from APTA that requiring 16 days of monitoring for codes 98980 and 98981 — treatment management codes that account for time spent in a calendar month — isn't appropriate for these types of services. CMS agreed, and clarified that the 16-day collection requirement doesn't apply to the two codes
October 2023
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July 2023
April 2023
Navigating Insurance – APTA RI Payment Committee Tips for success:
- Medicaid Renewal 2023 – RIAPTA has compiled resources to assist Practices help patients stay covered – Please review this resource
- UnitedHealth Tip
- Community Plan: To avoid denials, a taxonomy code is required in box 33b on the 1500 Form in order for claim to be processed
- Commercial Plans: Out of network denials could be occurring due to UHC system glitch – f/u with your representative if affecting your claims.
- Blue Cross - Anthem
- Out of State Authorization/Benefits: Use the 1-800- Number to assist with benefit determinations.
Adapted from APTA’s Friday Focus: Remote Therapeutic Monitoring: APTA Updates
- Updated RTM practice resource, advocated for continued patient access to RTM, and alerted MACs to denials they're making in error.
Cigna
On 3/2/23 APTA met with Cigna leadership. These meetings will be held 2x a year with the next in fall 2023. ASH leadership also joined at the suggestion of Cigna. Highlights are noted below:
- Direct access/ PT first: APTA expressed concern that Cigna medical policies do not clearly facilitate direct access. Cigna indicated active support for direct access and was surprised that providers were not clear on the need for a referral. Cigna understands the value of physical therapy and will continue to develop programs that enable conservative management. Cigna will review current stance on direct access and maybe add more communication to market, so policy is clear.
- PT in prevention and wellness
Discussed PT in prevention and wellness including the annua visit. Cigna relayed that coverage is benefit driven and both ASH and Cigna asked if there was evidence demonstrating that the annual visit is cost effective? There is currently no evidence and or expressed interest in implementing or conducting a pilot to collect data.
- Value based care opportunities
Cigna is primarily involved with surgical value-based models that extend from admission to hospital discharge. Possibly in the future they may consider include pre/post op PT, but no plans are imminent.
- Future of Telehealth
Both ASH and Cigna expressed support for continued remote services. Cigna: is looking at all aspects of telehealth including Remote Physiological Monitoring.
NIA/Magellan
National Imaging Associates: Physical Medicine – Guideline Pending - High Importance Update
Issued a new version of the document. Review date: 07/01/2023. Next review date (est.): 07/01/2024
View Full Policy - PDF View Full Policy - Payer Website
UHC
Upon a change in the UHC association leadership team, the meetings were postponed until the new staff was on boarded. The next meeting is currently planned for June 2023.
ASH- American Specialty Health
ASH Newsletter: https://www.ashlink.com/ash/WCMGenerated/JanFeb2023_RS_online_tcm17-213294.pdf
AIM
In March 2023, AIM Specialty Health® transitioned to Carelon Medical Benefits Management Inc. Per Anthem, “This transition is a name change only, and there will be no process changes”. If providers inquire, please let them know to check their February 2023 Anthem newsletter for the announcement. Here is info found during a google search.
- https://www.carelon.com/about-us?gclid=Cj0KCQiA6fafBhC1ARIsAIJjL8mLS9Jt4kXQBpLCPzLv6gqE45wDYLuRspz8LOPrtbYF-Uvd31Np1cYaApf9EALw_wcB&gclsrc=aw.ds
- https://www.xifin.com/resources/industry-news/202207/anthem-launches-carelon-wellpoint-ahead-elevance-health-rebrand,
- https://www.premera.com/ak/provider/news/reminders-updates/aim-transitions-to-carelon/
- https://www.fiercehealthcare.com/payers/elevance-healths-profits-dipped-949m-q4-revenue-grows
SecureCare (SC)
On 3/21 APTA and the pay chairs from MN and MI met to discuss the status of the SC implementations in their state. On 3/28 APTA met with SC to review the rehab program.
Additional Resources:
Prior Auth
January 2023
Neighborhood Health Plan -Integrity: Removed Prior Authorization requirement for PT and OT beyond 24 sessions per calendar year for INTEGRITY members, effective Jan. 1st 2023
More information: Physical-and-Occupational-Rehabilitation-Services-eff-1.01.23.pdf
ASH-American Specialty Health
New clinical guidelines were issued at the end of the year and can be found here
Article:
CMS rule aimed at improving Medicare Advantage draws praise | Healthcare Dive
Payment Resources:
State Payer Advocacy Resource Center (SPARC):
A joint initiative of payer resources brought to you by APTA and APTA Private Practice Section
