Representing PTs, PTAs, and Students
of Physical Therapy in Alaska

What is APTA doing for you?

What is APTA doing for you?



The threat of a hard cap is gone!

Among the provisions included in the new policy:

Claims that go above $2,010 (adjusted annually) still will require the use of the KX modifier for attestation that services are medically necessary.
The threshold for targeted medical review will be lowered from the current $3,700 to $3,000 through 2027; however, CMS will not receive any increased funding to pursue expanded medical review, and the overall number of targeted medical reviews is not expected to increase.
Claims that go above $3,000 will not automatically be subject to targeted medical review. Instead, only a percentage of providers who meet certain criteria will be targeted, such as those who have had a high claims denial percentage or have aberrant billing patterns compared with their peers. MIPS: In 2017 PQRS became a “legacy” program and was rolled into the Merit-based Incentive Payment System (MIPS).

MIPS = Merit Based Incentive Payment System: Like the previous PQRS program, requires providers to submit quality data throughout the year for an annual scoring. Unlike the PQRS program, MIPS requires reporting in 4 performance categories, several of which need to be reported electronically through registries or certified EHR vendors. Providers earn points in each category, producing a total annual MIPS score. That score will determine whether the providers earn a payment incentive, remain neutral in payment, or be subject to a penalty. As with PQRS, payment incentives and penalties under MIPS will kick in 2 years after the data-collection year. So, for example, if reporting were mandatory for PTs this year, MIPS data for 2018 would determine incentives and penalties in the 2020 payment year. Payment incentives and penalties are much higher under MIPS than they were under PQRS: plus and minus 4% in 2019, 5% in 2020, 7% in 2021, and 9% in 2022 and beyond.

Why should I care? MIPS is not perfect but it is a small stepping stone to collecting data that prove our value. Eventually use data for other insurers, it may help to get rid of utilization management (UM). We need to demonstrate outcomes to payers as they shift into value based payment.

MIPS start date January 1st 2019. For more information go to:

Webinar was held on October 16th – Free to members.

Decision does not need to be made in January.

Thank you to all those clinics/individual PTs and PTAs who continue to serve the Medicare community!

Outcomes Registry: Data collection for PT outcomes. Takes key pieces of information out. Pulls and extracts data e.g. people with similar diagnoses, able to view numbers, average change in function. Leverages data to use in practice. $299 a year per member. $399 if not a member.

Cost may be offset e.g. if participating in MIPS. See

The Registry will align with current and future quality and compliance programs required by payers, such as the new Merit-based Incentive Payment System (MIPS). Other professions have been doing this for many years. For FAQs go to:

POPTs: Physician owned practices/referral for profit: APTA supports excluding physical therapy services from the in-office ancillary services exception (IOAS) under the physician self-referral prohibition (commonly referred to as the Stark law). The expansive use of the IOAS exception by physicians in a manner not originally contemplated by the law undercuts the purpose of the law and substantially increases costs to the Medicare program and its beneficiaries.

APTA believes that this issue should be addressed as part of any fundamental delivery system reform and that it could provide cost savings to help support reform. APTA is also a founding member of the Alliance for Integrity in Medicine (AIM) Coalition, a consortium of organizations which advocates for Congress to address the IOAS loophole.

POPs federal legislation (not passed) that exclude Medicare payment except for rural areas (Rural exclusion). PT and radiology cannot be owned by physicians.

The state of Missouri for example has a ban on physician owned practices.

The RFP (referral for profit) Task Force has been busy developing several tools and legislative strategies to assist individuals and state chapters in our battle against referral for profit. The Task Force also developed the APTA White Paper on Referral for Profit (.pdf), which outlines and explains the reasons for the Association’s opposition to referral for profit and POPTS. In addition, APTA and the Task Force worked with a number of state chapters on their efforts to combat referral for profit through state legislation, most recently in South Carolina and Alabama.

Other initiatives include a grant program to help chapters develop and implement state legislative strategies and a presentation on RFP for distribution to educators for their PT and PTA students. APTA is also developing resources that physical therapists can use to adapt their practices to better compete with RFP entities, to develop guidelines for PTs who are acquiring physical therapy practices formerly owned by physicians, and to provide examples and clarification of appropriate business arrangements among PTs, physicians, and other practitioners or business entities.

Physical Therapist Ownership and Operation of Physical Therapy Services (.pdf)

Opposition to Physician Ownership of Physical Therapy Services (.pdf)

Health and Wellbeing: Insurance companies are beginning to fund wellness programs.

“APTA Council on Prevention, Health Promotion and Wellness” is new this year, 2018. See APTA communities up by the log in on the APTA website. Go to The Hub. Choose the community.

Open to Council members, APTA members and APTA staff.

The Council on Prevention, Health Promotion, and Wellness in Physical Therapy Community is a collaborative space to post, discuss, collaborate and generate innovative growth in the practice of prevention, wellness, fitness, health promotion and management of disease and disability in Physical Therapy. This community will serve as a resource for physical therapists as they continue in or expand their practice.

Value Based Payment Model: A toolkit is being developed to explain how this works. Fee for service may not go away completely. APTA is moving the discussion towards quality not just costs as more PT decreases total costs.

To prepare for value based care we need outcome tracking.

“In value based pricing you are telling the customer (patient, payer, employer), that you are good at what you do and can demonstrate that via your predictive pricing and outcome tracking. Your pricing is based upon your ability to know your outcomes, predict costs and therefore demonstrate your true value”. Some PT businesses are using this to market their services to businesses.

New 2018 Milliman Report by the Private Practice Section: “Impact of Physical Therapist Services on Low Back Pain Episodes of Care”. Available (to all) on the PPS website.


APTA is using this and many other studies to prove that insurances should be focused on PT and quicker access to PT to save them money. This report shows:

• If a physician chooses to refer a patient to a physical therapist, referrals sent early (in the first 14 days) will result in lower costs and less use of invasive/higher cost procedures. Earlier is better.

• When accessing physical therapy for LBP, direct access is the best and lowest cost method and will result in less use of invasive/higher cost procedures.

• Clinical care of patients with recommended/active care results in lower cost and quicker outcomes than with passive care. Active care is the best!

Opioid Crisis: Florida law now requires 20 hours education on prescribing that includes non pharmacological alternatives like PT. Perhaps Alaska should look into this? PTs need to part of the solution on how we talk about pain.

June 2018 – APTA released a white paper called “Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health.”

See APTA website. APTA isn’t a newcomer to the opioid fight. The association’s involvement dates back to late 2015 and includes the award-winning #ChoosePT Public Awareness Campaign. The white paper is a comprehensive summary of the problem and APTA’s recommendations to address it.

A quote from this paper: “Recent recommendations by the US Centers for Disease Control and Prevention (CDC) in its “Guideline for Prescribing Opioids for Chronic Pain.” The CDC states that “Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain.” The report expands on this thought, suggesting that “many non- pharmacologic therapies, including physical therapy…can ameliorate chronic pain.”

APTA is using the opioid crisis to point out that high deductible and copay plans add to the opioid crisis by being a barrier to physical therapy services.

Downstream PT saves money. Insurers are coming on board. Upstream and downstream potential savings e.g. versus imaging, surgery, drug use. BCBS of Vermont waived all copays for PT with this in mind. There were no increases in utilization or costs as a result as feared at first.

In Florida, they have launched a website and campaign to educate the public called Promotes PT and educates the public about direct access.

BCBS of Alaska and Evicore/CorePath: Survey to be rolled out this fall or possibly January 2019. This will help us gather data to help us workout strategies to deal with this issue e.g. Legislation like Washington state that prohibits pre authorization for the first month of PT treatment, this became law this summer. Quarterly conference calls are ongoing with APTA and BCBS/Evicore as well as a continuous dialog with APTA.

We have made a work sheet for clinics on Evicore/CorePath (available from Katie Piraino

Premera is reducing payment per CPT code by a significant amount for their preferred providers, they are moving to a RBVRS model. Clinics should have received notification of this. Time frame for implementation is 90 days.

I have formed a payment committee to discuss action. More information to follow.

Katie Piraino, PT.

Ph: 907 227 3119