payment for physical therapy care is changing · evolution of payment challenges payment challenges...

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What’s on the Horizon: Innovative Approaches to Advanced Physical

Therapy Practice

Elise Latawiec, PT, MPH

Senior Specialist, Payment and Practice Management

American Physical Therapy Association

Session Learning Objectives

After this session, you will be able to:

• Describe why the current procedural based reporting and payment system is an unsustainable model.

• Describe the various types of payment models and results to date.

• Identify payment/ healthcare trends.

• Understand the practice impacts and fundamentals of ICD10.

Payment for Physical Therapy Care is Changing

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Changing Environment

• Affordable Care Act established the Triple Aim

• New focus on patient-centered episodes of care, not silos of service-centered care

• Congressional mandate for quality reporting programs for all Medicare services

• Innovative payment methods focus on episodes of care and incorporate outcomes in the payment methodology

Health Care Reform: Triple Aim

Improved Access

Improved Quality

Accountability/ Cost

Containment

ACA Codified Triple Aim

• Established new payment models to encourage provider transition to patient centered care to achieve Triple Aim – Accountable care organizations- targeted

hospitals and physicians

– Medical homes- targeted physicians to coordinate care

– Bundled payments: targeted hospitals/ PAC providers or physicians to coordinate care

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Trends in PaymentCommercial Payer Policy

Taking (a few) pages from Medicare’s playbook in setting

fees and developing utilization strategies:• Coverage of services by PTA’s

• Application MPPR/ Sequestration

• Value based payment

• Network Adequacy

• Audit Activity – UM/UR

• Data Collection and Metrics

• Telemedicine

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Evolution of Payment Challenges

Payment Challenges (15% in 3 years / 3 New Requirements)

2011

First Application of MPPR (6‐7%)

2012

2‐Tier Cap Exceptions / Inclusion of Hospital OP Department

2013

MPPR Phase II (6‐7%)

Continuation of 2‐Tier Exceptions (Manual Medical Review)

Functional Measures Requirement

PQRS Penalty Phase

Blueprint for New Payment System• Over time, payers should largely eliminate stand-alone fee-for-service

payment to medical practices because of its inherent inefficiencies and problematic financial incentives.

• Fee-for-service contracts should always incorporate quality metrics into the negotiated reimbursement rates.

• For smaller practices, reimbursement changes should encourage methods to form virtual relationships and share resources to increase quality of care.

• Measures should be put in place to safeguard access to high-quality care, assess the adequacy of risk-adjustment indicators, and promote strong provider commitment to patients.

National Commission on Physician Payment Reform, March 2013 http://physicianpaymentcommission.org/report/

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Value-Based Health Care Payment Systems

Source: Miller HD. Creating payment systems to accelerate value‐driven health care: issues and options for policy reform. Commonwealth Fund pub no. 1062, September 2007; http://www.commonwealthfund.org

Most commonly seen today.

APTA’s PTCPS

Ideal Spot on Continuum

Value-Based Healthcare• CMS: Shifting payment incentives from

volume to value – Timeline announced January, 2015:

• 2016: 30% of FFS payments based on value and provided through alternative payment models

• 2018: 50% of FFS payments based on value and provided under alternative models that base payments on quality of care

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html

Value-Based Healthcare• CMS proposed mandatory hospital bundling

of TKR &THR – Announced July 2015

– Effective 1/1/2016 for 800 facilities across U.S.

– Covers hospital & post DC (extends to 90 days)

– 2014 CMS THR/TKR hospital costs alone $7B

• Health Care Transformation Task Force– Private payers to shift 75% of operations to contracts

designed to improve quality and lower costs by 2020

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Payment Reform Update:

Reporting Evaluation Services

Payment Reform for Rehab Services: Timelines and Guidance

Development of a Reformed Payment model

• Began post Balanced Budget Act 1997‐98

• Aggressively p/ 2010 w/ MPPR, MEDPAC

& legislative/regulatory pressures

• Working with AOTA and ASHA on future

revisions to the 97000 series of codes

• Start with evaluation codes

We can either drive the change or be driven by it

Consider these factors:

• Need to maintain clinicians ability to use their clinical judgment to provide medically necessary services in any alternative coding/payment methodology

• Patient characteristics, outcomes/value resulting from provider efforts should influence payment

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Overview of APTA OptionsAlternative Payment Methodology

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Consider these factors:

• Administratively burdensome policies would be lessened with focus moving away from controlling utilization towards managing patient progress, functional change and outcomes

• Transition to ICD‐10 provides an opportunity to incorporate ICF language into communications between rehab providers and payers

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Overview of APTA OptionsAlternative Payment Methodology

Key Characteristics of Reporting Services Under a Reformed Payment Method

• Factors include:

– Severity/complexity of the patients presentation

– Required intensity/complexity of the therapist clinical decision making

and skill/expertise

• Visit/Session Based Payment System

– Transition to reporting (coding) describing session rather than specific

interventions or unit based

– Based on clinical judgment of the therapist

• 97000 series collapsed (selected codes remaining separately reportable)

Future Payment Based On:Patient presentation and therapist clinical decision‐making

• Professional skill and judgment

• Mental and physical effort

• Psychological stress of impact of interventions

• Length of involvement to a limited extent

In other words, payment based on• Clinical decision making needed to address the severity (complexity)

• Intensity of services provided to progress toward return of function

Less Focus on Time spent More Focus on Clinical Decision Making

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Determining overall severity includes results of:

• History (medical, functional)

• Examination

• Physical impairment

• Impact on the patient ability to function

• Cognition

• Living environment

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Overview of Evaluation Coding Structure

3 levels of evaluation based on complexity– Low complexity

– Moderate complexity

– High complexity

Level of the PT evaluation dependent on clinical decision making/ nature of the condition (severity)

Overview of Evaluation Coding Structure

Patient history supports level of evaluation by addressing:

• Impact of comorbidities on function and ability to progress through a plan of care

• Previous and current functional abilities

• Past treatment approaches

• Factors impacting patient ability to progress

• Rationale/ medical necessity

DefinitionsEvaluation Coding Structure

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Personal Factors include:

• Sex, age, coping style, social background, education, profession, experiences

• Overall behavior patterns, character

• How disability is experienced by the individual

• If no impact on plan of care, personal factors should not be considered when selecting a level of service

DefinitionsEvaluation Coding Structure

CPT Code Revisions PT Evaluation- Low Complexity

History Examination Presentation Decision-Making

Problem focused, No personal factors and/or comorbidities that impact POC

Problem focused, addressing 1-2 body structures and functions, activity limitations and/or participation restrictions

Stable and/or uncomplicated characteristics

Low complexity, use of standardpatient assessment instrument and/or measurable assessment of functional outcome

CPT Code Revisions PT Evaluation- Moderate ComplexityHistory Examination Presentation Decision-Making

Expanded, 1-2 personal factorsand/or comorbidities that impact POC

Expanded, addressing 3 of any of the following body structures and functions, activity limitations and/or participation restrictions

Evolving with changing characteristics

Moderate complexity, use of standard patient assessment instrument and/or measurable assessment of functional outcome

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CPT Code Revisions PT Evaluation- High Complexity

History Examination Presentation Decision-Making

comprehensive, 3 or more personal factors and/or comorbidities that impact POC

Comprehensive, addressing 4 or more of any of the following body structures and functions, activity limitations and/or participation restrictions

Unstable andunpredictable characteristics

High complexity, use of standardpatient assessment instrument and/or measurable assessment of functional outcome

CPT Code RevisionsPT Re-evaluation

• Single level

• Re‐evaluation of established Plan of Care

• Examination including review of history, use of standardized tests and measures

• Revised POC based on standardized patient assessment instruments and/or measurable assessment of functional outcome

Relative-Value Update CommitteeRUC Process

In order to be establish values for these new codes for eventualinclusion on fee schedule (MPFS)

•APTA surveyed a random sample of the membership to assessthe “professional work” value of the new CPT codes related tophysical therapist evaluations and reevaluations.

•This survey is part of the AMA’s Relative Value Scale UpdateCommittee (RUC) process and will be used to develop valuerecommendations for these new codes. The valuerecommendations will eventually be submitted to CMS.

•If you have questions you can visit the APTA survey webpageat www.apta.org/RUCsurvey or email [email protected].

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Moving Forward

Continue effort to modernize code set to be able to assist clinicians to best communicate their clinical services in a contemporary health care environment in order to facilitate appropriate payment and clearly demonstrate the value of physical therapy to the health and wellness of the individual

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Key Documents Alternative Payment Methodology

• Familiarity with these resources will be helpful as coding and payment methodology reforms are discussed and developed– CMS Benefit Policy Manual, CH. 15, sec. 220.2, Reasonable and Necessary OP Rehab Services and 220.3, Documentation Requirements for Therapy Services

– International Classification of Function, Disability and Health, WHO, classifies health domains describing Body structures/functions, activities/participation and environmental context

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ResourcesAlternative Payment Methodology

‐International Classification of Function, Disability and Health http://www.who.int/publications/en/

‐Institute of Medicine, Crossing the Quality Chasm. A New Health System for the 21st century, National Academy Press 2001

‐MedPAC, report to Congress: Increasing the Value of Medicare, Ch. 6, June 2006 http://www.medpac.gov/

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Thank You!

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ICD 10

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ICD-10• Transition from ICD-9 to ICD-10 diagnosis

coding on October 1, 2015

• Used in all settings

• Applies to HIPAA covered programs

• Two different code sets

– ICD-10-CM: International Classification of Diseases, 10th Revision, Clinical Modification

– ICD-10-PCS: International Classification of Diseases, 10th Revision: Procedure Coding System

ICD-10

• For now, use CPT/HCPCS codes

• WC transition will vary by state

• MVA/Liability carriers not required to transition- check payer policy

• Experts advise cash reserves

• Check payer/ UM vendor policy for updates/ diagnoses exclusions

ICD10 Implementation: Billing

• Effective October 1, 2015 for HIPAA covered entities:– Claims must use ICD-10 CM diagnosis codes

– Claims w/ ICD-9 codes will not be accepted for dates of services post October 1, 2015

– Institutional providers Part A services: ICD 10 use based on discharge/ through date (use ICD10 on all cases for claims w/DOD post 10-1)

– Outpatient services -based on date of service

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Tips about the date

• Do not bill ICD-9 and ICD-10 codes on the same claim form

• Billing both codes on the same form will result in rejected claims

• Claims for services provided prior to October 1, 2015 must be billed separately

Outpatient Claim Submission

• Example 1

• Start episode on September 4th, 2015

• Discharge on September 30th, 2015

• Submit claim October 15th, 2015

• Use ICD-9

Outpatient Claim Submission

• Example 2• Start episode on September 25th, 2015

• Discharge on October 30th, 2015

• Submit claim November 15th, 2015

• Use ICD-9 for dates of service through September 30th

• Use ICD-10 for dates of service on or after October 1st, 2015

• May need to split claim

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Why the Transition?• ICD-9 Barriers:

– Outdated; developed in the 1970s based on medicine and technology no longer in use

– Lack of detail for payment for today’s treatments

– No space for new codes

• ICD-10 Benefits– Allows for greater detail for laterality, primary encounters,

external causes of injury, preventative health, as well as socioeconomic, family relationships, lifestyle related problems

– More space to accommodate evolving technology

– Supports exchange of health data with other countries (all other G-7 nations have transitioned to ICD-10 already)

ICD-10-CM “Official Guidelines”• ICD-10-CM developed and maintained by the World

Health Organization (WHO) and the National Center for Health Statistics within the Centers for Disease Control

• As with ICD-9-CM, ICD-10-CM is supplemented by a set of “Official Guidelines” that are designated as part of the ICD-10-CM code set by the HIPAA “medical data code set” regulations (45 CFR § 162.1002(C)(2))

• The Official Guidelines provide detailed guidance on the use of the ICD-10-CM code set– The 2015 ICD-10-CM Official Guidelines are available from

http://www.cdc.gov/nchs/icd/icd10cm.htm#icd2015

ICD-10 CM External Causes (Chapter 20)

• No national requirement for mandatory ICD-10-CM external cause code reporting

• External Cause is only required for providers subject to state-based external cause code reporting or payer requirement

(e.g. Fall from stairs and steps due to ice and snow – W00.1)

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Comparison ICD-9 and ICD-10ICD-9

• 3-5 Characters

• Diagnoses: 14,025

• Procedures: 3,824

• No laterality

• No combination codes

ICD-10

• 3-7 Characters

• Diagnoses: 69,099

• Procedures: 71,957

• Laterality (Left, right, bilateral)

• Combination codes

• Application of 7th

character

The GEMs

• CMS developed bidirectional crosswalks between ICD-9-CM and ICD-10-CM/PCS

• General Equivalence Mappings (GEMs)

• GEMs for > 99% ICD-10-CM codes; 100% ICD-10-PCS codes

• Limited applicability/ starting point only

How Different Is It?Example of ICD-9 to ICD-10

ICD-9-CM

820.02: Fracture of midcervical section of femur, closed

ICD-10-CM/PCS

S72031A, Displaced midcervical fracture of right femur, initial encounter for closed fracture

S72031G, Displaced midcervical fracture of right femur, subsequent encounter for closed fracture

with delayed healing

S72032A:Displaced midcervical fracture of left femur, initial encounter for closed fracture

S72032G: Displaced midcervical fracture of left femur; subsequent encounter for closed

fracture with delayed healing

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ICD-10 Code Breakdown• Up to 7 characters

• Alphabetic index: list of terms and corresponding codes

• Tabular list: chronological list of codes divided into chapters based on body system or condition

– Chapter 19 (injury) and Chapter 13 (musculoskeletal)

• Step 1: Look up term in alphabetic index

• Step 2: Verify code in tabular list

Category (first character always

alpha, second character numeric)

Category, anatomic site,

severity

Extension (initial encounter, subsequent

encounter, sequela)

Use of the 7th character

• Certain chapters use a 7th character (e.g. musculoskeletal, obstetrics, injuries, external causes)

• Different meaning depending on the section where it is used

• When 7th character applies, codes missing 7th character are invalid


• Initial encounter: Used as long as patient is receiving active treatment for condition.

–e.g. surgical treatment, emergency department care

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• Subsequent encounter: After patient completed active treatment and is receiving routine care during healing or recovery phase.

• Most physical therapy visits are subsequent encounters – e.g. post cast change or removal of external or

internal fixation device, medication adjustment, other aftercare and follow-up visits following treatment of the injury or illness

Use of the 7th Character

• Sequela: Complications or conditions that arise as a direct result of a condition

– e.g. scar formation after a burn

Example of 7th Character

S.43 Dislocation and sprain of joints and ligaments of shoulder girdle

• A Initial encounter

• D Subsequent encounter

• S Sequela

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Posterior dislocation of left acromioclavicular joint

• Patient is seen in emergency department

S43.152A (active treatment)

• Same patient is taken to surgery for treatment

S43.152 A (active treatment)

• Same patient is seen in follow-up physician visit to check healing

S43.152D (subsequent treatment)

• Same patient is seen by physical therapist

S43.152D (subsequent treatment)

Placeholder “X”

• X fills in empty characters if code contains fewer than 6 characters and a 7th character applies

• X is not case sensitive

• If X applies, it must be used for code to be valid

• Example: S43.1XXD (Subluxation and dislocation of acromioclavicular joint) subsequent encounter

ICD-10: Key Practice Impacts

Where are ICD-9 codes used today?– Paperwork – Electronic systems– Submitting reimbursement claims– Identifying patient eligibility– Prior authorization/ABNs– Reporting quality data– Payer coverage policies

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ICD 10: Key Practice Impacts • Documentation:

– ICD-10 code set provides greater specificity for patient diagnosis

– Must support ICD10 coding

– More specificity may be needed to demonstrate medical necessity

– Documentation auditing is recommended • http://www.apta.org/PeerReview/

ICD-10: Practice Impacts

• Staff Training: All staff that work with ICD-9 must be trained on ICD-10

– Clinicians

– Front desk staff

– Coding/billing staff

ICD-10: Key Practice Impacts

• Verify vendor – Readiness– Billing systems– Claims software

• Practices using electronic billing systems need the systems updated by the vendor

• Recommend participation w/ payer testing

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Practice Impacts

• Hard end stop ICD9 /start ICD10

• Don’t wait- prepare

• Obtain vendor transition plan

• Reach out to clearinghouse-submit test claims (especially if doing own billing)

• Get PT’s used to ICD10 coding now

• Assemble resources prior to 10/1/2015

• Cash flow depends on proper claim submission

• Develop cheat sheet for commonly used codes

CMS Efforts to Help Providers

• CMS to establish communication and collaboration center to resolve issues

• ICD-10 Ombudsman will receive and triage provider issues

• If Part B Medicare contractors are unable to process claims an advance payment may be available

CMS Efforts to Help Providers• I year grace period: “for 12 months after

ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule ... based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.“

• May not apply to other payers- verify

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APTA ICD 10 Resources

• http://www.apta.org/Payment/Coding/ICD10/

– Key Practice Impacts

– General information

– ICD-10 Official Guidelines

• Learning Center Webinar:

Implementing ICD-10 Diagnostic Codes (Recorded) Author(s): Janet Albanese, PT, MPT MHA, Joseph Nichols, MD

CMS ICD-10 Resources

• CMS Website on ICD-10 https://www.cms.gov/ICD10/

– CMS and AMA Announce Efforts to Help Providers Get Ready For ICD-10.

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf

• CMS ICD-10-CM Quick Reference Guidehttps://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.asp#TopOfPage

• Road to ICD10 http://www.roadto10.org/

APTA ICD-10 Resources

• http://www.apta.org/ICD10/

–Key Practice Impacts

–General information

–ICD-10 Official Guidelines

–More to Come

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Other ICD-10 Resources• AHIMA http://www.ahima.org/icd10

• ICD-10 Proposed and Final Rules– http://edocket.access.gpo.gov/2008/pdf/E8-19298.pdf

– http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf

• CDC Website on Classification of Diseases– http://www.cdc.gov/nchs/icd.htm

• ICD-10-CM Official Guidelines for Coding and Reporting – http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf

Other ICD 10 Resources

• ICD-10 Proposed and Final Rules– http://edocket.access.gpo.gov/2008/pdf/E8-19298.pdf– http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf

• CMS Website on ICD-10– https://www.cms.gov/ICD10/

• CDC Website on Classification of Diseases– http://www.cdc.gov/nchs/icd.htm

• ICD-10-CM Official Guidelines for Coding and Reporting – http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines

_2015.pdf

APTA Web Site

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Consolidation and Network Adequacy

Industrywide Consolidation

Large insurer acquisitions

•Centene & Healthnet

•Aetna & Humana

•Anthem & Cigna

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Impacts of Consolidation• Reduce top insurers from 5 to 3

• Anthem/Cigna

– 53 million enrollees

– 1.1 million Medicare Advantage

• United Healthcare



• Aetna



Provider Consolidation

Provider mergers and acquisitions

• Health systems

• Hospitals

• Physician groups

• Rehabilitation

• Pharmaceutical

Reasons for Consolidation

• Provider– Ensure viability in face of payment cuts/

declining negotiating power

• Payer

– Provider consolidation

– Rapidly escalating drug costs

– PPACA limited price increases

– Medical loss ratio (MLR)

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Insurer Growth Strategies

• PPACA created opportunity for millions of new customers

• Expand into growth markets

Medicaid

Medicare Advantage

• Fight for scale to maximize profitability

Impacts of Consolidation• Antitrust issues?

• Increased premiums?

• Lower payment to providers?

• Network changes?

• Quality metrics for network participation?

• Increased cost sharing?

• Utilization management/ review?

• Reduced provider ability to negotiate?

Consolidation Oversight

• Federal Trade Commission – Protect consumers

– Ensure strong competitive market

– Enforce consumer protection laws

– Enforce anti-trust laws

– Assess impact on consumer choice/ price

– Assess local market segment penetration

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Consolidation Oversight

• House Judiciary Committee

– 1st hearing scheduled Sept to discuss competition in healthcare marketplace

– Legislators to examine

• Increased consolidation

• Role of the PPACA in recent mergers

• Consumer impacts

What to do

• Monitor payer actions

• Pay close attention to contracts

• Monitor insurer correspondence for policy or network changes

• Contact Insurance Commissioner

• Outreach to legislators

What to do• FTC accepts public comments at:

https://www.ftc.gov/policy/public-comments or https://www.ftc.gov/policy/public-comments/advanced-comment-search.

• APTA will inform members if FTC issues formal request for public comment

• Watch for APTA updates

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Provider Networks

• Network Adequacy Standards established for Marketplace Plans– “Network of providers sufficient in number and

type to assure all services will be accessible without unreasonable delay.”

• States may have more stringent Network Adequacy standards

Insurer Perspective• Provisions of the Affordable Care Act increased

cost/risk:

– No medical exclusions

– No increased premium based on medical status

– Limited premium increase w/age

– Cover children to age 26

– Cover EHB

– No lifetime cap

Insurer Response

• Narrow/ ultra narrow networks

– Limit provider participation

– Selective contracting

– Drive volume to “value” providers

• Broad network = higher premium

• Limit out-of-network benefits

• Increase out-of-pocket costs

• Affects all market segments

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Issues• Adequate coverage?

• Patient Access?

• Availability of provider listings?

• Consumers informed?

• Premium vs out of pocket

• Affordability vs choice

• Bills for out of network services

• Numerous lawsuits

Regulatory Changes• National Association of Insurance Commissioners (NAIC) model

network adequacy regulation development in process:

– Balance stakeholders needs

– General vs. quantitative standards

– Address provider directory timeliness/accuracy

– Address tiered networks

• Federally Facilitated Marketplace regulation/guidance for 2015:

– FFM plans must submit list in network:

• Hospitals

• Mental health

• Oncology

• Primary Care

Medicare Advantage call letter February 2015

• Acknowledge network adequacy concerns

• Accessible, real time directory updates

• Pilots to assess plan compliance

• Improve enrollee determination/ appeal grievance process

• Document effort to obtain clinical info

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Medicare Advantage APTA asks

• Process for provider/ enrollee feedback• Accommodate enrollee special needs • Out of network service at no added cost if in

network provider not accessible in timely manner

• Qualified reviewers• Track inconsistent policy determinations

Medicaid Plans

• 73% Medicaid recipients (43 million) in MCO’s

• #’s in Medicaid plans growing due to PPACA

• Adequate networks a challenge in rural areas

• Criticized for inadequate networks/ denying care

CMS Medicaid Proposed RuleMay 2015

• Caps insurer profits (Med Loss Ratio)

• Require states to supervise plan NA

Poor prior enforcement

• Establish provider network standards

Time/ distance for Hospitals, OB-GYN, PCP

• Require multilingual providers

• Pushback from State Medicaid Directors/ insurers

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Medicaid Proposed RuleAPTA asks

• Time/distance standards for all Essential Health Benefit providers

• Minimum network adequacy requirements for exceptions

• Monitor provider gain/ loss as Medicaid enrollment grows

• Regularly seek stakeholder feedback on network adequacy

NA Trends

• ½ exchange silver plans are narrow network– Include 25% or < physicians in a rating area

– > CA, FL, GA, OK/ none 12 states incl. OR, CT, MO

– Differ by plan type: >HMO, <PPO

• Broad network premium 13-17% higher

• Cheaper premiums appeal to price sensitive consumers

• Consumers willing to trade choice for price

• Employers slowly following trend

NA TrendsRobert Wood Johnson Narrow Network study, 6/2015

• “Can quantify narrowness or size of a network”

• “While consumers are likely to select plans with low premiums, they are not fully aware of the characteristics of narrow networks.”

• “Well-functioning narrow networks will survive only if their characteristics are communicated more clearly to consumers and they are regulated to ensure adequacy.”

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NA Trends• 2016 Exchange plans will be required to

– Update provider directories monthly

– Include 30% of community providers

• In remote/rural regions narrow networks & regulatory parameters not practical

• Mississippi, South Dakota, others: AWP laws in response to narrow networks

• April 2015 NY law protects patients from unexpected out of network bills

NA Trends

• In network facilities w/ OON providers– Radiologists, anesthesiologists, ER docs

• ACA regulated ER out of pocket to in network patient cost sharing

• ACA does not prohibit balance billing in states where it is allowed

• 13 states restrict OON provider balance billing if consumer is insured

NA Trends

• 2014 CA customers filed class action suit against Anthem/BS of CA/ Cigna re: inaccurate doctor/ hospital directories

• NY State Attorney General settled w/ Emblem Health & agreed to IN coverage of anesthesia for colonoscopy

• Cancer/Children’s hospitals suing plans for exclusion due to higher prices

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NA Trends

• Health Systems creating SNF networks to:

– Shorten lengths of stay

– Reduce hospital readmission

– Increase/ control quality & costs

– Hold providers accountable

• 20% Medicare patients: hospital to SNF

• Traditional Medicare patients have choice

• Hospitals use quality of care rationale

NA TrendsAvalere Health Study

Marketplace vs. employer based plans offer:

• 33% fewer choice of in network providers

• 32% fewer PCP’s/ behavioral health providers

• 42% fewer oncology/ cardiology providers

• 25% fewer hospitals

NA TrendsAlliance for Health Reform Briefing July 1, 2015

• http://www.allhealth.org/briefing_detail.asp?bi=367

• Era of selective contracting

• Plan labels (PPO, HMO, EPO) don’t say much about robustness of network

• Consumers unable to determine providers prior to plan selection

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• 2014 Georgetown University study of NA standards at state level – 50% or 23 states: quantitative standards (e.g.

max travel time and distance)

– 10 states: provider to enrollee ratios

– 11 states: max wait times for appointments

– Some applied only to HMO’s


• State NA activity– Ark & WA: quantitative standards for 2015

– CA: DOJ filed new NA regulations

– CA, CT, NV, NY, WA: empowered regulators to assess networks/ engage payers

– Several states addressed provider directories

• Policy issues– Little data on what works in specific states or regions

– Network impact on price

– Balancing act between price, access & choice

What APTA and Chapters are doing:

• Advocate on behalf of the profession

• APTA monitors Federal regulations

• Chapters monitor state specific NA standards

• APTA/ chapters comment on proposed regs

• Align with other stakeholders

• Keep members informed

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Provider Tips

• Check to see if more stringent network adequacy standards apply in your state

• If your facility is seeing narrow networks, collect anecdotal evidence of patient access issues

– Document all reported issues

– Advise consumers to report concerns to insurer, employer, Office of the Insurance Commissioner (OIC)

• Use outcome data, cost data, and niche services to leverage in-network contracts

Utilization Management / Utilization Review Companies

Background

• Increased third party UM for rehabilitation

• Partnering between APTA and Chapters

• Identify and address issues

– Regence BC (payer)/ Care Core (UM)

• WA, OR, UT, ID

• Effective January 2014

– Cigna (payer)/American Specialty Health (UM)

• TX, CA, NV, AZ

• Effective 8/1/14 Texas

• Effective 1/1/2015 CA, NV, AZ

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Upcoming UM Implementations

• ASH/Orthonet switch Cigna/ Anthem CT 1/1/16

• ASH coming to Illinois

• Orthonet contract w/ Anthem

– CA, IN, KY, MO, OH, WI: 11/1/2015 full risk plans

– IN, KY, MO, OH, WI: 11/1/2015 national plans/ state exchange

– KY, OH, MO, WI: 1/1/16 Medicare Advantage

– KY, WI, OH, IN: 1/1/16 Managed Medicaid

Major Issues w/UM Companies• Policy

– Definition medical necessity – Assessment of function – Determination/ criteria for visit approval

• System – Failed/untested technology– Administrative burden– Delayed authorization approvals– Inaccurate provider network status– Inaccurate or inability to determine eligibility – Claims issues– Tiering

• Patient Access– Interrupted treatment– Denied/delayed approval medical necessary services

How we got here

• Health care reform eliminated insurers ability to use pre-existing conditions and lifetime limits as a barrier to insurance coverage.

• Insurers re-calculated actuarial tables and determined costs would increase.

• Insurers maximize their control over costs by Counting/Limiting Procedures, (CLP)

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Contributing factors

• Growth delegated UM attributed to two factors:

– Unabated increase PT spend

– Provision of the Affordable Care Act: Medical loss ratio

• Purpose: limit insurer profit

• Insurer must spend specific % premium $ for medical care

• Premium rebates if medical % not met

• 2014 rebates totaled $330 million

Med Loss Ratio

– Med sized companies: 80% medical/ 20% administrative

– Large sized companies: 85% medical/ 15% administrative

– UM/ quality management for prospective and concurrent review included in medical

– Outsourcing allows payer to fix cost– Reduces administrative/increases medical

spend– Reduces rebates

Insurer Goals

• Reduce cost

• Control utilization

• Address outliers

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Value-Based Utilization Management

What needs to change

• PT must assume identity of a VALUE to be leveraged in driving positive outcomes to meet the “triple aim”… not a COST to be contained by counting procedures

• Data demonstrating VALUE of PT

• Facilitate Direct Access

• Get PT out of silo into total episodic cost of care

• Collaborate w/stakeholders

Factors potentially impacting UM • Triple aim • Shift to value based payment• Health Care delivery reform (ACO, PCMH)• Risk sharing/ bundled payment arrangements• Data collection/focus on outcomes• Increased cost sharing• PTCPS (payment reform) • Direct Access• Mergers and acquisitions

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Utilization Management Feedback Form

Purpose:

– Give members a voice

– Collect data UM related issues (track & trend)

– Provide member resolution assistance

– Use data to effect vendor change

– Use data to inform alternative UM strategy

– Facilitate UM vendor relationship building

UM Related Initiatives

• Started UM Tool Kit for chapters

• Developing UM member resources

• Online UM data collection tool

• Peer Review resources

• Integrity in Practice Campaign

• Registry

• CPG development/ The Guide to Practice

Experience to date

• APTA lessons learned…..

– What works

– What doesn’t

– Successes

• What’s next….

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APTA Recommendations

• Appeal all denials

• Continue to submit claims post denial

• Keep record of patient out of pocket

• Appeals increase UM company costs

• Payer tracks appeals

• Provider due diligence required prior to Insurance Commissioner outreach

APTA UM Feedback Form

• http://www.apta.org/Payment/PrivateInsurance/TPAUtilizationMgmtReview/

• http://www.apta.org/Payment/PrivateInsurance/TPAUtilizationMgmtReview/FeedbackForm/

Direct Access

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2015 DA Survey

• Initial survey completed 2009 • National Survey 2015:

– Compare use of DA w/ states surveyed 2009– Identify settings using direct access– Assess awareness of state regulations – Determine detrimental provisions/restrictions – Identify barriers to payment – Identify effective marketing strategies

APTA DA Goals

• Eliminate legislative restrictions (state & federal)

• Secure payment for DA services

• Facilitate patient access

• Improve affordability

• Encourage best models of care delivery

• Educate PT’s, consumer, payer/self insured employer on benefits DA

DA Survey Results

• Sent to approx. 60,000 PT members

• Total responses: 5951

• Percentage by practice setting – 43% private practice

– 24% out patient hospital

• Percentage treating DA patients– 50% yes (same)

– 48% no (same)

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DA Survey Results

• Surveyed member patient population: – Medicare 35%

– Commercial 34%

– Medicaid 11%

– Workers’ Comp 9%

– Self pay 7%

DA Survey Results• Top reasons providers not using DA

– 65% Supervisor/facility requires referral

– 25% Patients not aware of DA

– 23% Don’t know which payers allow DA

– 16% Reimbursement concerns

• DA patient population– 44% Self pay

– 25% Commercial payers

– 6% Medicare

– Many respondents unsure of payer type

DA Survey Results• Members promoting DA?

– Yes 73%

– No 21%

• How is DA promoted? – 70% Marketing to patients

– 53% Community event participation

– 48% Educating referral sources

– 30% Online advertising

– 28% Sponsoring community events

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DA Survey Results

• Reported 7.5% DA claims denied

• Denial of payment for no referral?– 22% yes (same)

– 37% no (same)

– 41% respondents unsure (same)

• Services provided via DA– 94% Traditional (same)

– 44% Fitness/wellness/health promotion (same)

– 40% Screenings (same)

DA Survey Results• Barriers to increasing DA

– 54% yes (FL 64%)

– 46% no (FL 36%)

• Common barriers– 60% Reimbursement concerns (FL 70%)

– 28% Lack marketing skills (FL 21%)

– 24% Fear alienating referral sources (FL 14%)

– 21% Restrictions by employer (FL18%)

– 21% Lack knowledge state DA laws (FL 27%)

DA Survey Results

• Provisions / restrictions state practice act impacting ability to use DA

– 41% Time and visit limits (FL 77%)

– 28% Referral needed for certain treatments (FL 22%)

– 22% Don’t know (FL 5%)

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UPDATES

THANK YOU [email protected]