1 Looking for your feedback!SPEAK UP! CAMPAIGN Looking for your feedback! PPTA Reimbursement and Regulation Update Fall 2016
2 The experiences of patients do matterThe experiences of patients do matter. Consistent and repetitive communication by the consumer will eventually get the ear of legislators, the employer (particularly the self-insured), and the insurance commissioner. Delays in authorization approval, visits approved in small increments with waits in between, or denial of medically necessary services, and high copays that interfere with plans of care are all examples of access issues.
3 SPEAK UP! S P E A K U Excessive cost sharing = cost shifting … cost shifting results in delayed access or no access to care… delayed access/no access increases the potential for downstream costs CPT coding used to define benefits results in unnecessary cost sharing … same provider, treating within their scope of practice, two copays because of Highmark’s benefit structure? Fairness in copay act outlawed this practice, but Highmark continues to peddle this option with their self-insured plans. PPTA Reimbursement and Regulation Update Fall 2016
4 SPEAK UP! Send a letter or make a phone call to legislators, employers, HR departments, insurance companies, newspapers. To find a PA legislator gislator/ To find your US Representative To find your US Senator
5 Provide templates and facilitate communication!SPEAK UP! Provide templates and facilitate communication!
6 SPEAK UP! Every visit counts! Appeal UR decisions and challenge time lags that interfere with medically necessary plans of care!
7 Access to care issues should be challenged and reported!SPEAK UP! Access to care issues should be challenged and reported!
8 SPEAK UP! Know the law! File complaints with the PA Insurance Department/PA Department of Health! The insurance commissioner’s job is to protect consumers, patients with access issues should communicate with the PID as that office is particularly interested in hearing about access issues.
9 SPEAK UP! Use your appeal power!
10 Patient involvement matters! Engage them!SPEAK UP! Patient involvement matters! Engage them!
11 How do we engage them? Make it easy to SPEAK UP!
12 Sample Template: Authorization processI have paid an insurance premium that indicates my physical therapy benefit includes (X) number of visits per benefit period. After performing an examination and evaluation of my problem, my physical therapist developed an individualized plan of care that included (X) number of visits. The physical therapist was required by (HEALTH INSURANCE PLAN) to submit their plan of care for approval, and only (X) number of visits were approved.
13 Sample Template (cont’d)After completing the approved number of visits, and in order to access the remaining number of medically necessary treatments in my plan of care, my PT was required to request authorization for additional visits. These visits were approved. The additional paper work required by (HEALTH INSURANCE PLAN) interrupted access to care that I have paid a premium for and added cost to the system by a burdensome and unnecessary review process.
14 Sample Template (cont’d)I placed my trust in the clinical judgment of my physical therapist, licensed in the state of Pennsylvania and required to comply with the PA Physical Therapy Practice Act. I attempted to access a benefit for which I have paid my premium, yet (HEALTH INSURANCE PLAN) placed a restriction on my benefit. If I purchase a dozen eggs at my grocery store, I don’t need to ask permission of the owner to eat the eggs.
15 Sample Template (cont’d)(HEALTH INSURANCE PLAN) requires a cost sharing copay of ($ copay amount per visit) to encourage appropriate utilization of my benefit. Their ability to further restrict my access and reduce their risk, based on their approval or disapproval of my therapist’s plan of care, is an unfair administrative policy that seems to benefit (HEALTH INSURANCE PLAN) financially. I am very interested in receiving a response regarding these authorization policies that restrict access to care.
16 Other template topics you’d like to have developed?Send your ideas to the PPTA Payment Specialist
17 Action Plan: Excessive copays (When does cost-sharing = cost shiftingLegislative efforts to tie the max copay to the amount of a PCP copay have been unsuccessful to date. Grassroots communication from providers, and more importantly, patients, may help to build momentum toward introducing legislation in the future to reduce the burdensome cost- shifting to patients.
18 Speak UP when excessive copays are limiting access to care! Action Plan: Excessive copays (When does cost-sharing = cost shifting?) Speak UP when excessive copays are limiting access to care! Patients and providers are encouraged to communicate with their legislators, employers and the Pennsylvania Insurance Department when copays approach or exceed the reimbursement from the payer. AFTER: Legislative efforts to tie the max copay to the amount of a PCP copay have been unsuccessful to date. Grassroots communication from providers, and more importantly, patients, may help to build momentum toward re- introducing legislation in the future to reduce the burdensome cost- shifting to patients. PPTA Reimbursement and Regulation Update Fall 2016
19 Front Office staff are a critical point of contact!What tools would help them to encourage patients to SPEAK UP!
20 Action Plan: Double copays and double visit deductions in self-insured plans – SPEAK UP!Identify self-insured employers whose rehab benefit includes the double copay and communicate that information to the PPTA Payment Specialist Encourage patients to inform their employer of the impact of this double copay policy… many don’t understand patients pay two copays to see the same provider on one date of service! Encourage patients to file a complaint with the PID … even though as a self insured plan this is out of the purview of the PID, numerous complaints might trigger their communication with another governmental agency. The complaint might include that even though Act 39 prohibits this practice, Highmark continues to provide this as an option to employers. Identify self-insured employers whose rehab benefit includes the double copay and communicate that information to the PPTA Payment Specialist A violation of this article is deemed an unfair method of competition and an unfair deceptive act or practice pursuant to the Unfair Insurance Practices Act.” If you can confirm that these plans are not self-insured plans and are continuing to charge the double copay and the extra visit, complaints should definitely be filed with the PA Insurance Department. Here’s a link to Act 39 You might consider sending this along with your appeals. Also, do you think any of your patients would be willing to send a letter to Highmark and/or to their legislator if we provided a template for the letter? I have been in discussion with the PA Insurance Department and the Department of Health about multiple Highmark issues and the advice I’m getting is to get the patients involved in filing complaints about this process. Finally, once you determine if these plans are, in fact, not self-insured, and at your convenience, please forward as much detail from the EOB that identifies these plans and I’ll share with other providers so they can be on the lookout… I suspect many are not appealing because they assume they are self-insured plans. Thanks in advance for any information you can provide. PPTA Reimbursement and Regulation Update Fall 2016
21 Action Plan: Double copays and double visit deductions in self-insured plans – SPEAK UP!Encourage patients to inform their employer of the impact of this double copay policy… many employers don’t understand their employees must pay two copays to see the same provider on one date of service! Seek information about who makes decisions about the insurance plan and share that with the PPTA Payment Specialist.
22 Action Plan: Double copays and double visit deductions in self-insured plans – SPEAK UP!Encourage patients to file a complaint with the PID … The complaint should point out that even though the Fairness in Copay Act outlawed this practice, Highmark continues to provide this as a “cost-sharing” option to self-insured employers.
23 Action Plan: Double copays and double visit deductions in self-insured plans – SPEAK UP!Because self insured plans are not regulated by the PID, the patient should include “If you aren’t able to take action against double copays/double visits, how can a complaint be filed against a self-insured plan?
24 Utilization Review – SPEAK UP!Demand PT reviewer Use the APTA UM Feedback Form Document the impact of delayed approvals Facilitate patient reporting about the impact of UR/UM policies– help them SPEAK UP! Chapter outreach to PID Due diligence required prior to PID action PPTA Reimbursement and Regulation Update Fall 2016
25 Please forward policies and guidelines for major payers in PA to the PPTA Payment SpecialistAs I mentioned earlier, the source of this policy revision information was the CBC Professional Administrative Bulletin: 2016P I’m embarking on an initiative to identify and review PT related policies for delivering PT services in PA. Please send any policies, links to policies, update notices etc. to me. Don’t worry about duplications, I’ll sort through them! PPTA Reimbursement and Regulation Update Fall 2016