AN UPDATE FROM THE AKAPTA PAYMENT CHAIR
On September 25, 2018, Premera Blue Cross Blue Shield of Alaska sent a letter to preferred providers, including physical therapists, informing of a change in payment from the Usual and Customary Rate (UCR) to a Resource Based Relative Value Scale (RBRVS). Premera may have also attached a Fee Schedule Update effective January 1, 2019, along with a Conversion Factor for physical medicine and speech therapy.
What can you do as an individual practitioner?
In order to clearly determine the impact of the Premera payment change on your practice, we suggest you take a few key steps outlined below. This will help you to factually identify contract changes that have occurred as well as the reductions in reimbursement, impact on your practice and the patients you serve.
Review this document on contracting, negotiating and knowing your costs: http://www.apta.org/Payment/PrivateInsurance/ManagedCareContractingToolkit/
You need to know your cost of doing business or what it costs you to provide a physical therapy visit. If you are not familiar with how to do this, we recommend reviewing the following APTA resources: http://www.apta.org/Payment/PrivateInsurance/ManagedCareContractingToolkit/http://www.apta.org/Payment/Billing/KnowYourCosts/
To calculate the cost per visit, simply calculate your total cost for a year (or other defined time period of your choice). Include the owner’s salary in the calculation. You should consider adding 10% or another number of your choice to represent the profit margin required to stay in business. Divide that number by the number of visits for that same time period. That would be your cost per visit. You can then compare your cost per visit with the reimbursement for a typical visit from a Blue Cross Blue Shield of Alaska. You should consider reducing that amount by 10% (or another variable) to allow for uncollected fees.
Once you complete the calculation, it may be used to make a business decisions on determining whether or not the practice is accepting contracted rates that are less than it costs to provide a visit. There may or may not be reasons the practice chooses to do so, but it should always be based on knowledge of the numbers and a sound business decision. If the practice contracted rate is less than the practice cost per visit, the practice has several options:
a. Reduce expenses, and therefore practice cost per visit
b. Increase volume of visits, without increasing expenses (likely sacrificing quality, outcomes, or regulatory requirements)
c. Renegotiate contracts, or
d. Cancel any contracts that are causing a loss in revenue or facilitating poor choices for the clinic.
If the practice chooses to attempt to renegotiate a contract, you must contact your local provider representative.
AK PTA encourages members who contract with Premera to contact their local Provider Relations Representatives to relay the impact of the contract changes on the practice, provision of services and patient access.
The practice may choose to go out of network. This would allow balance billing of the patient for any amount the insurance does not cover above the typical copay and deductible. Refer to this resource for further information: http://www.apta.org/Payment/Billing/CashPractice/OutofNetwork/
Next steps and chapter resources
Should you decide to go out of network, provide your patients a letter explaining your decision. (CLICK HERE)
Provide your patients a sample letter to share with their employer if their plan is employment based. (CLICK HERE)
Educate patients who buy their own insurance on assessing their options.
Provide your patients a sample letter to share with the Director of Insurance in Alaska. (CLICK HERE)
AKAPTA members benefit from this assistance from the Chapter to help navigate ongoing changes with private payers.
ALASKA PAYMENT NEWS
Julie Ament, PT, DPT, OCS, MOMT
New Evaluation Codes for 2017
A new CPT evaluation coding system started on January 1, 2017. Three new codes-97161, 97162, and 97163- replace the single 97001 CPT code for physical therapy evaluation.
With that in mind, here are 6 worthwhile resources that can help you understand and prepare for the big change in coding. Go to APTA.org to learn more including a self-paced course.
This course is designed to introduce physical therapists to the new evaluation and reevaluation codes, and teach therapists how to select the appropriate evaluation code based on patient presentation. Physical therapists will select the appropriate evaluation level based on the following components: patient history, examination, patient presentation, and complexity of clinical decision making. A feature of this course is a self-paced review of patient scenarios specific to a variety of physical therapist practice specialties: cardiovascular and pulmonary, geriatrics, neurology, orthopedics and pediatrics.
PTs in Alaska can now use Locum Tenens for Physical Therapy Coverage of Medicare Patients
In signing the 21st Century Care Act into law on December 13, 2016, President Barack Obama ensured that physical therapists (PTs) would gain something APTA has been working on for several years-the ability to provide care continuity for patients in the PTs absence through a provision known as “locum tenens.”
The final version of the legislation applies only to PTs in non-Metropolitan Statistical Areas, Medically Underserved Areas, and Health Professions Shortage Areas as defined by the US Department of Health and Human Services. Looking at this reference it seems all of Alaska is included in the Medically Underserved Areas. Check it specifically for your location.
More Changes to Come for Workers Compensation Fee Schedule
We can expect more changes to payments for physical therapy services in April 2017. There was a WC Board meeting on January 12-13, 2017 to discuss amendments to the fee schedule implemented in 2016. Our Chapter is currently working on deciphering the meaning and effect of the proposed new Medical Fee Schedule and making comments.
Click HERE to read publications to date.
Julie Ament, PT, DPT, OCS, MOMT
AK Chapter Payment Chair
New Premera Blue Shield of Alaska Pre-Authorization Requirement
Effective July 1, 2016, Premera Blue Shield of Alaska began to require medical necessity review and authorization through a third party administrator, eviCore healthcare (formerly CareCore), for outpatient rehabilitation services provided by physicians, practitioners including physical therapists, and facilities for services such as physical therapy, occupational therapy and massage therapy. Services in conjunction with an inpatient stay, a twenty-three hour observation or emergency room are not subject to determination requirements and authorization.
Beginning July 1st, for Premera insured patients being evaluated for outpatient therapy services or for patients continuing in an outpatient rehabilitation, plan of care need to have a treatment plan submitted to eviCore healthcare for medical necessity review and authorization of services after the initial visit. eviCore is to respond to the request within two business days. eviCore will provide an authorization/ notification number and date range that will ensure payment by Premera. Services determined not medically necessary will be denied. Typically eviCore is authorizing 6-10 sessions.
Premera is requiring all providers (in-network and out-of-network) to complete the eviCore authorization process. If an out-of-network provider does not request an authorization, Premera will pend that provider’s claim and will then notify them of the requirement for a review by eviCore. If the out of network provider completes the authorization process after receiving the communication and the services are deemed as medically necessary, Premera will process the providers claim when they receive the authorization from eviCore. If the provider does not complete the authorization process after receiving a communication from either Premera or the local Blues plan, the claim will be processed after a specific period of time and will likely be denied because medical necessity could not be established.
Providers need to register to have access to the eviCore Healthcare site to submit treatment plans for authorization. This can be done by going to CareCoreNational.com to create an account. You can also call eviCore at 800-792-8751 for assistance.
eviCore Healthcare is offering web based orientation sessions for Premera’s providers. Some have already occurred. Go to http://medsolutions.Webex.com/ and select Training Center from the top menu bar to look for Upcoming Premera Provider Orientation Sessions.
The Alaska Chapter is working with the Washington Chapter and APTA to have ongoing meetings with Premera Blue Shield and eviCore to work out kinks and voice problems as they occur. Please email me problems as they arise so that I may educate Premera and eviCore of issues we as providers are finding.
The Workers’ Compensation Medical Fee Schedule has changed effective December 1, 2015.
Click HERE to read the details of Register 217, April 2016 LABOR AND WORKFORCE DEV.
In summary, the emergency amendment of 8 AAC 45.082(m) is made permanent such that the Official Alaska Workers’ Compensation Medical Fee Schedule, effective December 31, 2010, is no longer valid as of December 1, 2015.
In most cases the fee schedule has changed to a Resource – Based Relative Value Scale (RBRVS) like Medicare uses but with a conversion factor established by the Workers’ Compensation Act. As an example, for medical services provided by hospital outpatient clinics or ambulatory surgical centers under AS 23.30, an outpatient conversion factor of $221.79 is to be applied to the relative weights established for each Current Procedural Terminology or Ambulatory Payment Classifications code.
Physical Therapists practicing outside of hospitals or ambulatory surgery centers have a different fee schedule not based on RBRVS. The text in section (l) is as follows:
“For medical treatment or services provided by other providers, the maximum allowable reimbursement for medical services provided by providers other than physicians, hospitals, outpatient clinics, or ambulatory surgical centers, is the lowest of 85 percent of billed charges, the fee or charge for the treatment or service when provided to the general public, or the fee or charge for the treatment or service negotiated by the provider and the employer.”
Another change in the Workers’ Compensation Act effective December 1 2015 is the definition of provider which does reference physical therapists as follows:
“The emergency adoption of 8 AAC 45.900(a)(15) is made permanent to read: “provider” means any physician, pharmacist, dentist, or other health service worker or any hospital, clinic, or other facility licensed under AS 08 to furnish medical or dental services, including chiropractic, physical therapy, and mental health services; (B) includes an out-of-state person or facility that meets the requirements of this section and is otherwise qualified to be licensed under AS 08.”
Functionally, private practice physical therapists are noticing that the payers of Workers’ Compensation Physical Therapy claims are generally not paying correctly. Most often an appeal of the claim is needed with reference to 8AAC45.082 section (l), in order to get proper payment. The hope is that once the payers get the formula correct in their systems that payment should be correct ongoing. Appealing incorrect payment helps everyone.
The Alaska Department of Labor and Workforce Development published an emergency Regulation as of December 1, 2015 to amend section 8 AAC 45 in regard to payment for Medical Treatment and Services.
The Regulation notes that a fee or charge for medical treatment or services provided before December 1, 2015 may not exceed the Boards fees established in the Official Alaska Workers’ Compensation Medical Fee Schedule, effective December 31, 2010.
It adds that a fee or charge for medical treatment or services provided on or after December 1, 2015 may not exceed the fee schedules set out in this section (8 AAC 45.083).
Most medical treatments are converted to a Resource Based Relative Value Scale (RVRBS) with conversion factors provided in the regulation for different medical services and treatment providers.
Physical Therapists in private practice; however, fall udder section (l): for medical treatment or services provided by other providers the maximum allowable reimbursement for medical services provided by providers other than physicians, hospitals, outpatient clinics or ambulatory surgery centers shall be the lower of 85% of billed charges, the fee or charge for treatment or service when provided to the general public, or the fee or charge for treatment of service negotiated by the provider and the employer. (Outpatient clinics are defined earlier in regulation and does not define outpatient physical therapy clinics).
Julie Ament, PT, DPT, OCS, MOMT
AK Chapter Payment Chair