By Kelly Huestis
As Section on Women’s Health Reimbursement Committee chair, I am fortunate to attend the APTA State Policy and Payment Forum annually. For therapists of women’s and men’s health, let’s be honest–payment can be one of the most aggravating and unfamiliar aspects of our job. Indeed, this forum changes my perspective on payment every year! I’m especially thankful for the latest payment updates. Here are some of the hot topics:
- Workers compensation rates are decreasing in some states in an effort to allow more people to grow their businesses. Emerging trends in this area include opioid misuse and encouragement to wear activity and location trackers. Often associated with low back pain, opioid prescriptions can lead to other costlier interventions rather than physical therapy. Thus, the #ChoosePT campaign was born!
- The Health Care Exchange has been a frustration for many payers with too much risk. Payers see providers paying premiums for clients; loss due to the “grace period;” and too many opportunities for people to go on and off the exchanges, particularly when they are sick.
- For 2017, Humana and UHC/Aetna will be reducing their participation. Cigna and Anthem sustained losses and are continuing with caution. Centene (which just acquired Healthnet) and Molina are doing well and plan to continue. Expect a volatile environment in 2017, since there will be premium hikes, payers coming on and off, and reduced out-of-network coverage.
- Manual Therapy Charges. Some issues have arisen in a few states around denial of CPT 97140. Some overutilization has drawn increased scrutiny to this code. This seems to be payer- and state-specific. If you experience an issue, contact your state APTA reimbursement chair.
- MACRA Act of 2015 (Medicare Access and CHIP Reauthorization Act of 2015).This is the legislation that repeals the sustainable growth rate formula (SGR), ties in merit-based incentives for quality reporting, and encourages alternative payment models such as accountable care organizations and bundled payment. Those participating in alternative payment models will receive a 5% bonus payment if participating from 2019 to 2024. However, there are stipulations: They must be risk-based and have no fee-for-service (think Joint Replacement Program), and it requires an increasing percentage of patients in the Advanced Alternative Payments Models annually.
- Targeted Manual Medical Review also is implemented through MACRA and looks at providers with aberrant billing practices, high claims denial percentages, and newly enrolled providers. The emphasis is on the number of units/hours of therapy provided in a day and looks at 40 claims per provider.
- New evaluation codes are coming in 2017! Episodic care is the payment model of the future. The American Physical Therapy Association will be launching an educational campaign to help physical therapists comply with the new codes. Be aware that although CMS will accept the codes for 2017, they will reimburse all new codes at the same rate. They are concerned about upcoding. Each new code has four components of complexity and severity. Remember that your documentation must show consistency on all four levels to determine the level of complexity. More to come on this in future blog posts by the SOWH Reimbursement Committee!
- Tricare Reorganization. Humana Military and Health net services will manage the Tricare system. Look for significant reductions in PT payment rates.
Keep an eye on the SOWH Reimbursement website page for ongoing payment updates and guidelines.